Inspection Reports for Brentwood Health and Rehabilitation

A State Licensure survey was conducted at MGHP Brentwood from June 13, 2025, through June 15, 2025, to assess compliance with state health regulations and identify any deficiencies.

The survey revealed multiple deficiencies including failure to maintain resident privacy during care, improper implementation of oxygen therapy care plans for three residents, improper storage of clean and soiled linen carts increasing infection risk, and inadequate labeling and sanitation of food items and dumpsters posing risks of food-borne illness and pest infestation.

A standard survey was conducted from June 13, 2025 through June 15, 2025, including investigation of Complaint Intake Number GA00254017 in conjunction with the standard survey.

The facility was found not in substantial compliance with Medicare/Medicaid regulations with multiple deficiencies including failure to maintain resident dignity and privacy, failure to refer a resident for PASRR Level II screening, failure to implement care plans for oxygen therapy, failure to administer oxygen as ordered, failure to prevent avoidable falls, failure to post daily nursing staffing numbers, failure to properly label and date food items, failure to maintain dumpsters in sanitary condition, and failure to separate clean and soiled linen carts to prevent infection.

Complaint Intake Number GA00254017 was investigated and substantiated with no deficiencies found related to the complaint.

The visit was conducted to perform a Life Safety Code Survey and review the Emergency Preparedness Program for Brentwood Health and Rehabilitation.

The facility was found not in substantial compliance with Life Safety Code requirements, specifically related to sprinkler system maintenance and combustible decorations. Electrical wiring was observed lying on sprinkler piping affecting 50% of the facility, and several resident room curtains were not fire retardant.

An abbreviated/partial extended survey was conducted to investigate complaint GA00247059.

The complaint GA00247059 was unsubstantiated and no deficiencies were cited related to the complaint.

Complaint GA00247059 was investigated and found to be unsubstantiated.

A Follow-Up Survey was conducted to verify correction of previously cited survey deficiencies.

All previously cited survey tags have been corrected as noted by the surveyor during the follow-up visit.

This document is a Statement of Deficiencies and Plan of Correction for Brentwood Health and Rehabilitation following a survey completed on 10/11/2023.

The report contains initial comments but does not provide detailed findings or deficiencies in the provided page.

An unannounced visit was conducted to investigate complaint GA00238652 in conjunction with a Revisit Survey from 10/10/2023 to 10/11/2023.

The complaint GA00238652 was found to be unsubstantiated with no deficiencies identified during the visit.

Complaint GA00238652 was investigated and found unsubstantiated with no deficiencies.

A revisit survey was conducted to verify correction of deficiencies cited in the 8/24/2023 Standard Survey and to investigate Complaint Intake Number GA00238652.

All deficiencies cited in the 8/24/2023 Standard Survey were found to be corrected. The complaint investigation for GA00238652 was unsubstantiated with no deficiencies identified.

Complaint Intake Number GA00238652 was investigated and found to be unsubstantiated with no deficiencies.

A standard recertification survey was conducted at MGHP-Brentwood Health and Rehabilitation from August 22, 2023 to August 24, 2023 to assess compliance with Medicare/Medicaid regulations.

The facility was found not in substantial compliance with Medicare/Medicaid regulations, with deficiencies including failure to submit Minimum Data Sets (MDS) assessments within required timeframes for five residents and failure to ensure psychotropic medications were not ordered as needed (PRN) for more than 14 days without clinical indication for two residents.

A State Licensure survey was conducted at MGHP-Brentwood from August 22, 2023 through August 24, 2023 to assess compliance with state health regulations.

The facility failed to ensure that psychotropic medications, including antianxiety and antidepressant medications, were not ordered as needed (PRN) for more than 14 days unless clinically indicated for two of five residents reviewed. Specifically, orders for lorazepam lacked appropriate stop dates or clinical rationale for continuation beyond 14 days.

The inspection was conducted as a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and related fire safety standards.

The facility was found not in substantial compliance with multiple Life Safety Code requirements including emergency preparedness program deficiencies, fire door locking and closing issues, ceiling tile openings, missing door closers, fire alarm system deficiencies, sprinkler system maintenance issues, blocked fire extinguishers, improperly sealed firewalls, electrical hazards, and blocked electrical panels.

An abbreviated survey was conducted to investigate complaint GA00224317.

The complaint was unsubstantiated and no deficiencies were cited during the survey.

Complaint GA00224317 was investigated and found to be unsubstantiated with no deficiencies cited.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found to be in substantial compliance with the Emergency Preparedness Program requirements and Life Safety Code standards.

The inspection was conducted as a Licensure Survey from November 2, 2021 through November 4, 2021 to assess compliance for facility licensure renewal.

No deficiencies were identified during the licensure survey conducted from November 2 through November 4, 2021.

A standard survey was conducted at Brentwood Health and Rehabilitation from 11/2/21 through 11/4/21 to assess compliance with Medicare/Medicaid regulations.

The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 Code of Federal Regulations Part 483, Subpart B-Requirements for Long Term Care Facilities.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with federal regulations related to COVID-19 preparedness and infection control.

The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and has implemented CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19 preparedness and infection control regulations.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing recommended practices to prepare for COVID-19.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices related to COVID-19.

The facility was found to be in compliance with 42 CFR §483.73 and §483.80 infection control regulations and had implemented recommended practices to prepare for COVID-19.

A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.

The surveyor noted that all previously cited survey tags have been corrected during the follow-up visit.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance with life safety requirements due to failures in emergency lighting, fire sprinkler system maintenance and testing, smoke barrier door maintenance, and electrical system labeling and maintenance.

An abbreviated/partial extended survey was conducted to investigate complaints GA00196467, GA00196648, and GA00196705.

The complaints investigated during the survey were unsubstantiated and no deficiencies were found.

The complaints GA00196467, GA00196648, and GA00196705 were investigated and found to be unsubstantiated with no deficiencies.

An abbreviated/partial extended survey was conducted to investigate complaint GA00195290.

The complaint was unsubstantiated and no deficiencies were found during the survey.

Complaint GA00195290 was investigated and found to be unsubstantiated with no deficiencies.

A revisit survey was conducted from August 20 through August 22, 2018 to investigate complaint intake numbers GA00190355 and GA00190934 and to verify correction of deficiencies cited in the extended recertification survey conducted June 16 through June 22, 2018.

All deficiencies cited in the prior extended recertification survey were found to be corrected. The complaint investigation found the facility to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.

Complaint Intake Number GA00190355 and GA00190934 were investigated and found to be in substantial compliance.

A revisit survey was conducted to investigate complaint intake numbers GA00190355 and GA00190934 and to verify correction of deficiencies cited in the prior extended recertification survey conducted June 16-22, 2018.

All deficiencies cited in the prior extended recertification survey were found to be corrected. The complaint investigation found the facility to be in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B.

Complaint Intake Number GA00190355 and GA00190934 were investigated and found to be in substantial compliance.

A Follow-Up Survey was conducted to verify that all previously cited survey tags have been corrected.

The survey noted that all previously cited survey tags have been corrected.

An Extended Recertification survey was conducted at Brentwood Health and Rehabilitation on 6/18/18 through 6/22/18 due to concerns including multiple resident falls with injuries and an ongoing Immediate Jeopardy related to these issues.

The facility was found not in substantial compliance with Medicare/Medicaid regulations due to failure to consistently determine the root cause of falls, evaluate and revise care plans with appropriate interventions, provide adequate supervision to prevent falls, maintain sufficient staffing especially in the Memory Care Unit, and ensure effective oversight by administration and the governing body. Immediate Jeopardy was identified related to multiple residents sustaining serious injuries from falls. Corrective actions were validated by the State Survey Agency but the facility remains out of compliance as systematic changes continue.

The inspection was conducted due to a complaint investigation related to falls with fractures involving four residents, with concerns about the facility's failure to implement an effective falls prevention program and adequate staffing to prevent accidents.

The facility was found to have immediate jeopardy related to ineffective falls prevention, inadequate supervision, failure to determine root causes of falls, and insufficient staffing. Four residents had multiple falls resulting in fractures. The facility implemented corrective actions including reassessment of residents, therapy evaluations, staff education, and systemic changes to staffing and fall prevention protocols. Immediate jeopardy was removed on 6/30/18 but the facility remained out of compliance while implementing systematic changes.

The visit was complaint-related due to multiple falls with fractures among residents. Immediate jeopardy was identified as of 12/1/17 and was ongoing at time of exit on 6/22/18. An acceptable Credible Allegation of Compliance was received on 6/29/18, removing the immediate jeopardy on 6/30/18.

An Extended Recertification survey was conducted to determine compliance with Medicare/Medicaid regulations and assess falls management and resident safety.

The facility was found not in substantial compliance due to failure to consistently evaluate and revise care plans after falls, inadequate supervision to prevent falls, insufficient nursing staff, and ineffective quality assurance processes related to falls management for four residents with multiple falls and fractures.

Life Safety Code Survey conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance with life safety requirements, including failure to maintain exit ramps, emergency lighting, exit signage, fire sprinkler system maintenance, electrical wiring, and oxygen cylinder safety, placing residents and staff at risk in the event of fire or emergency.

A Follow-Up Survey was conducted to verify that all previously cited survey tags had been corrected.

The survey noted that all previously cited deficiencies had been corrected.

A standard survey was conducted at Brentwood Health and Rehabilitation from July 10, 2017, through July 13, 2017, to assess compliance with Medicare/Medicaid regulations.

The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations at 42 CFR Part 483, Subpart B - Requirements for Long Term Care Facilities.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the NFPA 101 Life Safety Code 2012 edition.

The facility was found not in substantial compliance with fire safety requirements, including failures in maintaining door closures, emergency lighting, vertical and horizontal penetrations, sprinkler system maintenance, fire walls, and electrical safety. These deficiencies could place all 85 residents and staff at risk in the event of a fire.

A follow-up survey was conducted on 5/17/17 to verify correction of deficiencies identified during the complaint survey of 4/1/17.

All deficiencies identified in the complaint survey of 4/1/17 had been corrected by the time of the follow-up survey on 5/17/17.

An Abbreviated Survey was conducted to investigate complaints GA00173276, GA00169822, GA00164768 and GA00158781. Two complaints were not substantiated, one was substantiated with no deficiency cited, and one was substantiated with deficiencies cited.

The facility failed to develop a comprehensive, individualized care plan with appropriate interventions for the care of a colostomy and colostomy bag for one resident (R#3). The colostomy bag was not monitored or emptied in a timely manner, causing discomfort to the resident. Additionally, the facility failed to post nurse staffing data daily for public review as required.

The survey was conducted in response to complaints GA00173276, GA00169822, GA00164768 and GA00158781. Complaints GA00164768 and GA00158781 were not substantiated. GA00173276 was substantiated with no deficiency cited. GA00169822 was substantiated with deficiencies cited.