Inspection Report
Plan of Correction
Deficiencies: 0
Sep 2, 2025
Visit Reason
An off-site desk audit was conducted to review all previous deficiencies cited on 7/25/2025 and verify corrective actions.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Census: 88
Capacity: 96
Deficiencies: 6
Jul 25, 2025
Visit Reason
The document is a Plan of Correction (POC) submitted by Brentwood Health Center following a recertification and complaint surveys conducted from 7/22/2025 through 7/25/2025 to address identified deficiencies and demonstrate compliance with federal regulations.
Findings
Deficiencies were identified related to notification of changes in resident condition, professional standards of care, quality of care, food safety, nursing services, and environmental conditions. The facility failed to notify physicians timely, ensure proper documentation and follow-up, and maintain food safety standards among other issues.
Severity Breakdown
Level D: 5
Level F: 1
Deficiencies (6)
| Description | Severity |
|---|---|
| Failure to immediately inform the resident's physician and notify the resident representative of changes in condition requiring physician intervention. | Level D |
| Failure to meet professional standards of care related to oxygen utilization and weight monitoring. | Level D |
| Failure to provide quality of care including timely notification of changes in condition and fall prevention. | Level D |
| Failure to provide appropriate treatment and services for urinary incontinence. | Level D |
| Failure to ensure food safety and sanitation in the main kitchen and food service areas. | Level F |
| Failure to maintain a safe, functional, sanitary, and comfortable environment for residents and staff. | Level D |
Report Facts
Census: 88
Total Capacity: 96
Date of Survey: Jul 25, 2025
Deficiency Count: 6
Inspection Report
Annual Inspection
Census: 88
Capacity: 96
Deficiencies: 8
Jul 25, 2025
Visit Reason
A recertification and complaint surveys were conducted at Brentwood Health Center from 7/22/2025 through 7/25/2025 to determine compliance with 42 C.F.R. Part 483, requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were identified as a result of the survey, including failures to immediately notify the resident's physician of a significant change in condition, failure to meet professional standards of care, failure to monitor and document weight discrepancies and orthostatic blood pressures, inadequate quality of care related to oxygen administration and fall risk, failure to provide appropriate bowel and bladder care, insufficient nursing staff competencies, and food safety violations. No life safety code deficiencies were identified.
Severity Breakdown
Level D: 7
Level F: 1
Deficiencies (8)
| Description | Severity |
|---|---|
| Failure to immediately notify the resident's physician of a significant change in condition resulting in transfer to acute care hospital. | Level D |
| Failure to ensure services provided meet professional standards of quality for multiple residents. | Level D |
| Failure to monitor and document orthostatic blood pressures and weight discrepancies as per facility policy and physician orders. | Level D |
| Failure to provide necessary treatment and care in accordance with professional standards related to oxygen administration and fall risk. | Level D |
| Failure to provide appropriate bowel and bladder care and treatment for residents with incontinence and constipation. | Level D |
| Failure to ensure nursing staff have appropriate competencies and skills to provide care and identify changes in condition. | Level D |
| Failure to store, prepare, distribute and serve food in accordance with professional standards for food service safety, including unclean equipment and uncovered food trays. | Level F |
| Failure to maintain a safe, functional, sanitary, and comfortable environment related to food trays left in hallways with partially consumed meals. | Level D |
Report Facts
Census: 88
Total Capacity: 96
Deficiencies cited: 8
Inspection Report
Follow-Up
Deficiencies: 0
Aug 14, 2024
Visit Reason
A follow-up off-site desk audit and a follow-up Life Safety survey were conducted to verify correction of previous deficiencies cited on July 11, 2024.
Findings
All previous deficiencies have been corrected based on acceptable plans of correction and supporting documentation. No new deficiencies were identified, and the facility is in compliance with all regulations surveyed.
Inspection Report
Plan of Correction
Deficiencies: 0
Aug 14, 2024
Visit Reason
An off-site desk audit was conducted on August 14, 2024, to review all previous deficiencies cited on July 11, 2024.
Findings
Based on an acceptable plan of correction and supporting documentation, all deficiencies have been corrected and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 86
Capacity: 96
Deficiencies: 13
Jul 11, 2024
Visit Reason
A Recertification Survey and complaint investigation survey were conducted at Brentwood Nursing Home from 7/9/2024 through 7/11/2024 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness.
Findings
Deficiencies were cited related to resident rights, notice requirements before transfer/discharge, dialysis care, nurse aide performance review, medication management, food safety, infection control, emergency preparedness, and life safety code compliance. The facility failed to provide adequate communication support for residents with limited English proficiency and failed to maintain proper documentation and procedures in several areas.
Complaint Details
The survey included a complaint investigation as referenced by ACTS Reference Numbers 96263 and 96457. The complaint investigation focused on resident rights, communication barriers, and quality of care issues.
Deficiencies (13)
| Description |
|---|
| Failure to treat residents with respect and dignity, especially for residents whose primary language is not the dominant language of the facility. |
| Failure to provide proper notice before transfer or discharge to the Office of the State Long-Term Care Ombudsman for discharged residents. |
| Failure to ensure residents receiving dialysis receive services consistent with professional standards, including proper documentation and physician orders. |
| Failure to complete annual performance reviews for nursing assistants. |
| Failure to ensure residents are free of significant medication errors, including missed insulin doses. |
| Failure to properly label and store drugs and biologics in locked compartments with proper temperature controls. |
| Failure to provide residents with suitable nourishing snacks at bedtime. |
| Failure to prepare, store, and distribute food according to professional standards of food service safety. |
| Failure to maintain infection prevention and control program to prevent transmission of communicable diseases and multidrug-resistant organisms. |
| Failure to conduct emergency preparedness exercises and maintain emergency plans as required. |
| Failure to maintain sprinkler system installation and life safety code compliance. |
| Failure to maintain electrical systems and emergency power supply in accordance with NFPA standards. |
| Failure to maintain oxygen cylinders and storage in accordance with fire safety regulations. |
Report Facts
Capacity: 96
Census: 86
Dates of survey: Survey conducted from 2024-07-09 through 2024-07-11
Deficiency completion dates: Plan of Correction completion dates mostly 2024-08-10
Resident counts: 86
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Social Worker | Interviewed regarding resident assessments and communication barriers |
| Staff B | Nursing Assistant | Interviewed regarding communication difficulties with resident |
| Staff C | Licensed Practical Nurse | Observed and interviewed regarding resident care and communication barriers |
| Staff E | Occupational Therapy Assistant | Interviewed regarding communication with resident |
| Staff F | Registered Nurse | Interviewed regarding dialysis care and medication administration |
| Staff G | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff H | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff I | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff J | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff K | Nursing Assistant | Named in deficiency related to performance evaluations |
| Staff L | Licensed Practical Nurse | Interviewed regarding medication administration |
| Staff M | Dietary Cook | Named in deficiency related to food safety manager license |
| Staff N | Housekeeper | Observed during infection control deficiency related to PPE use |
| Staff O | Registered Nurse | Observed performing wound dressing change |
| Director of Nursing | Director of Nursing Services | Responsible for implementing plans of correction and interviewed regarding deficiencies |
| Administrator | Facility Administrator | Interviewed regarding emergency preparedness and food service |
| Maintenance Director | Maintenance Director | Interviewed regarding life safety and sprinkler system deficiencies |
| Interim Regional Maintenance Director | Interim Regional Maintenance Director | Interviewed regarding life safety and sprinkler system deficiencies |
Inspection Report
Re-Inspection
Deficiencies: 0
Jun 29, 2023
Visit Reason
A revisit survey was conducted on June 29, 2023, for all previous deficiencies cited on May 17, 2023, related to the Re-certification/Licensure Life Safety Code survey.
Findings
All deficiencies have been corrected and no new noncompliance was found. The facility is in compliance with all regulations surveyed.
Inspection Report
Follow-Up
Deficiencies: 0
Jun 22, 2023
Visit Reason
A follow-up to a previous recertification survey conducted at this facility to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified during this follow-up survey.
Inspection Report
Complaint Investigation
Deficiencies: 9
May 22, 2023
Visit Reason
A Recertification Survey and complaint investigation was conducted at Brentwood Nursing Home from 5/15/2023 through 5/22/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, including state licensure and emergency preparedness surveys.
Findings
Deficiencies were cited related to failure to meet professional standards of quality in comprehensive care plans, including incomplete skin integrity observations, improper medication administration, inadequate incontinence care, failure to maintain nutritional status, food safety violations, infection prevention and control issues, and failure to provide adequate training and documentation for staff.
Complaint Details
The survey included a complaint investigation under ACTS Reference Number 90145. Deficiencies were cited as a result of this complaint investigation and recertification survey.
Deficiencies (9)
| Description |
|---|
| Failure to meet professional standards of quality in comprehensive care plans, including incomplete weekly skin integrity observations for multiple residents. |
| Medication administration error where a medication labeled 'Do not crush' was crushed and mixed with apple sauce. |
| Failure to ensure appropriate care and monitoring for residents with urinary and bowel incontinence, including improper catheter care and placement. |
| Failure to maintain acceptable nutritional status for residents, including failure to monitor weight changes and notify responsible parties. |
| Food safety violations including expired and spoiled food items, improper storage and handling of food, and failure to discard contaminated food. |
| Failure to provide adequate facility assessment and staff training related to obtaining resident weights. |
| Infection prevention and control deficiencies including improper handling of soiled linens, failure to maintain isolation precautions, and inadequate staff education. |
| Failure to ensure resident call lights were accessible and within reach, and failure to provide education to staff regarding call light use. |
| Failure to provide adequate Quality Assurance and Performance Improvement (QAPI) program training and documentation. |
Report Facts
Medication administration instances: 53
Weight loss percentage: 21.64
Weight loss percentage: 6.32
Weight loss percentage: 5.61
Resident weights reviewed: 7
Residents reviewed for skin integrity observations: 8
Residents reviewed for nutritional status: 4
Residents reviewed for catheter care: 5
Residents reviewed for call light accessibility: 5
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff C | Medication Technician | Observed crushing medication labeled 'Do not crush' and administering it to a resident. |
| Staff B | Licensed Practical Nurse (LPN) | Acknowledged skin integrity observation documentation was not completed as ordered. |
| Staff D | Nursing Assistant | Acknowledged catheter drainage bag was placed directly on the floor and not in a privacy bag. |
| Staff S | Nursing Assistant | Observed exiting a resident's room holding a soiled sheet and acknowledged usual practice. |
| Staff Q | Registered Nurse | Observed call light out of resident's reach and acknowledged resident would not be able to access it. |
| Staff T | Unit Assistant | Indicated making beds for residents and was unaware of any precautions in place. |
| Staff G | Dietitian | Unaware of resident weight loss and lack of nutrition plan for resident. |
| Staff H | Licensed Practical Nurse | Monitors all resident weights and runs monthly weight report. |
| Administrator | Unaware that newly hired Nursing Assistants did not receive training on obtaining resident weights. | |
| Director of Nursing Services | Unaware that newly hired Nursing Assistants did not receive training on obtaining resident weights. | |
| Director of Nursing Services | Interviewed regarding skin integrity observation documentation and infection control. | |
| Infection Control Nurse | Interviewed regarding infection control practices and observations. |
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