Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brentwood Health Center By Harborview during CMS and state inspections, most recent first.
Surveyors found that multiple food items in kitchen storage were not properly labeled with open or discard dates, and some lacked expiration dates after being removed from original packaging. Despite staff education and facility policy requiring labeling, items such as cooked meats, baked goods, produce, and bulk ingredients were observed with incomplete or missing labels during the kitchen inspection.
Staff did not maintain two dumpsters in a sanitary condition, leaving them with large gaps and missing doors for several months. This resulted in unsecured trash and exposure to pests, contrary to facility policy. Staff confirmed the issue had persisted despite requests for city repairs.
Clean linen carts were repeatedly observed stored directly next to or touching soiled linen carts containing visibly soiled linen on multiple halls. Interviews with the DON, ICP, and Administrator confirmed that this practice was not in accordance with infection control policy and increased the risk of cross-contamination.
A resident with severe cognitive impairment and multiple medical conditions was provided personal hygiene and incontinent care by a CNA without the privacy curtain being pulled and with window blinds open, resulting in a lack of visual privacy. The CNA acknowledged the failure to provide privacy, and both the Administrator and DON confirmed that privacy curtains should be used during ADL care.
A resident with multiple mental health diagnoses, including bipolar disorder, depression, anxiety, and psychosis, was admitted and received antipsychotic medications, but the required PASRR Level II referral was not completed. Staff interviews confirmed the oversight and the absence of documentation for the necessary evaluation.
Three residents with chronic respiratory and cardiac conditions were observed receiving oxygen therapy at flow rates that did not match their physician-ordered care plans. Despite having documented care plans and orders specifying the correct oxygen settings, staff administered oxygen at incorrect rates, which was confirmed by both LPNs and the DON during interviews and observations.
A resident with severe cognitive impairment and a high risk for falls was left unattended in a raised bed by a CNA, contrary to established fall prevention protocols. Both the LPN and DON confirmed the expectation that the bed should be in the lowest position when the resident is unattended, but this was not followed, resulting in a deficiency related to accident hazards and supervision.
Three residents with respiratory and cardiac conditions did not receive oxygen therapy at the flow rates ordered by their physicians. Observations revealed that oxygen was administered at incorrect rates, sometimes lower and sometimes higher than prescribed, and staff confirmed these discrepancies. Facility policy required staff to follow physician orders for oxygen administration, but this was not consistently done, as verified by direct observation and staff interviews.
The facility did not post required daily nurse staffing information in a visible location, as confirmed by observations and staff interviews. The posting had not been updated for several weeks, and key staff members were unaware of who was responsible for ensuring compliance with the policy.
Failure to Label and Date Food Items in Kitchen Storage
Penalty
Summary
The facility failed to ensure that food items in the kitchen were consistently labeled with open and/or discard dates and were discarded on or before the appropriate dates, as required by facility policy. During a kitchen tour, multiple food items in both the walk-in freezer and cooler were found either missing required labels, such as open or discard dates, or lacking expiration dates altogether. Items included pre-cooked biscuits, raw ribs, chicken pieces, corned beef brisket, French fries, sliced squash, pre-cooked pepperoni, coconut cream pie, cooked noodles, sliced peaches, cooked ground beef with spaghetti sauce, pudding, applesauce, cooked hamburger meat, and bulk bins of flour, sugar, and cornmeal. These items had either incomplete labeling or no labeling at all after being removed from their original packaging. Staff interviews confirmed that dietary staff had received education on proper labeling procedures, which included placing received dates, opening dates, and use-by or expiration dates on all food items. The Dietary Manager reviewed the findings and confirmed that staff should label all food products with the appropriate dates once removed from their original containers. Despite these policies and staff education, the observed deficiencies in labeling and dating of food items were present at the time of the survey.
Improper Maintenance of Dumpsters Leads to Sanitation Deficiency
Penalty
Summary
Staff failed to maintain two of three facility dumpsters in a sanitary condition, as required by the facility's Garbage and Rubbish Disposal policy. Observations revealed that the dumpsters had large gaps between the lids and were missing doors, resulting in unsecured trash and exposure to insects and rodents. One dumpster door was found propped against the building wall, and staff interviews confirmed that the doors had been off the dumpsters for three to four months. The facility policy specifies that outside dumpsters must be kept closed and free of litter, but this was not followed. Interviews with the Dietary Manager and Receptionist confirmed that the problems with the dumpsters, including missing doors and damaged lids, had existed since at least April. Both staff members reported reaching out to the city for repairs and replacement of the dumpsters, but no action was taken by the city until after the surveyor identified the issue. The lack of fitted lids and doors on the dumpsters created the potential for pest and rodent exposure, as well as unsanitary conditions.
Improper Storage of Clean and Soiled Linen Carts
Penalty
Summary
The facility failed to ensure proper separation of clean and soiled linen carts on three of five halls, as required by their Infection Prevention and Control Program policy. Multiple observations revealed that clean linen carts were stored directly next to or touching soiled linen carts containing visibly soiled linen on the 300, 400, and 500 Halls. These incidents were observed on several occasions, with clean and soiled carts being side by side or in direct contact in the hallways by various rooms. Interviews with the Director of Nursing, Infection Preventionist, and Administrator confirmed that the clean linen carts should not be stored in close proximity to soiled linen carts to prevent cross-contamination. All three staff members acknowledged that the carts were improperly stored and that this practice was not in accordance with the facility's infection control policies. The facility's policy and staff statements indicated that such storage practices could contribute to the spread of infection.
Failure to Provide Visual Privacy During Personal Care
Penalty
Summary
Staff failed to maintain the dignity and privacy of a resident with moderate intellectual disability, epilepsy, chronic kidney disease, and anxiety disorder. The resident, who had severe cognitive impairment and required assistance with activities of daily living, was observed receiving personal hygiene and incontinent care from a CNA while the privacy curtain was not pulled and the window blinds were open. This allowed full visual observation of the resident, who was wearing only a brief, by anyone in the hallway, anyone entering the room, and the resident's roommate. During the incident, the CNA acknowledged not providing privacy by failing to pull the curtain and stated that he should have done so. Both the Administrator and DON confirmed in interviews that privacy curtains are expected to be pulled to encircle the resident's bed during ADL care. The lack of privacy during care was directly observed and confirmed by staff interviews.
Failure to Refer Resident with Mental Health Diagnoses for PASRR Level II Evaluation
Penalty
Summary
A deficiency occurred when the facility failed to ensure that a resident with multiple qualifying mental health diagnoses was referred for a Level II Preadmission Screening and Resident Review (PASRR). The resident was admitted with diagnoses including bipolar II disorder, obsessive-compulsive behavior, major depressive disorder, anxiety disorder, and psychosis. Review of the resident's records, including the Annual Minimum Data Set (MDS) and care plan, confirmed the presence of these diagnoses and the use of antipsychotic medications. However, there was no evidence in the clinical record of a PASRR Level II evaluation being completed or submitted. Interviews with facility staff, including the Admissions Coordinator, DON, and Administrator, confirmed that the PASRR Level I screening was completed and present in the record, but the required Level II referral for residents with qualifying diagnoses had not been made. The DON and Administrator both acknowledged that the resident met criteria for a Level II PASRR and that it was the responsibility of the Social Worker to ensure the referral was submitted. No documentation could be provided to show that a PASRR Level II had been requested or completed for this resident.
Failure to Implement Physician-Ordered Oxygen Therapy as Outlined in Care Plans
Penalty
Summary
The facility failed to implement comprehensive care plans for three residents who were receiving oxygen therapy, as required by physician orders and facility policy. Each resident had a documented care plan and physician order specifying the exact oxygen flow rate to be administered via nasal cannula. However, direct observations on multiple occasions revealed that the oxygen flow rates being delivered did not match the physician's orders. For example, one resident with chronic obstructive pulmonary disease and other comorbidities was observed receiving oxygen at 3.5 LPM instead of the ordered 4 LPM. Another resident with similar diagnoses was observed receiving oxygen at both lower and higher rates than prescribed, including an instance where the flow rate was set at 7 LPM instead of the ordered 5 LPM, which was confirmed as an error by the LPN present. A third resident was also observed receiving oxygen at rates above the as-needed order, with staff confirming the settings were incorrect. Interviews with facility staff, including the DON and MDS Coordinator, confirmed that the care plans were in place and that staff were expected to follow the physician's orders as outlined in those plans. The facility's own policy requires individualized, comprehensive care plans with measurable interventions and timetables, and specifies that interventions should be implemented as ordered. The failure to administer oxygen therapy according to the care plans and physician orders constituted a deficiency, as it resulted in residents not receiving care and treatment as specified for their medical needs.
Resident Left Unattended in Raised Bed Despite High Fall Risk
Penalty
Summary
A deficiency occurred when a resident with multiple diagnoses, including epilepsy, chronic moderate intellectual disability, chronic kidney disease, bilateral cataracts, anxiety disorder, and hypertension, was left unattended in bed with the bed raised to a high position. The resident's records indicated severe cognitive impairment, a high risk for falls, and a need for assistance with all activities of daily living. The care plan specifically identified a risk for falls and a history of previous falls, with a goal to prevent fall-related injuries. On the day of the incident, a CNA exited the resident's room, leaving the bed in a high position and the resident unattended. Both the CNA and an LPN confirmed that the resident was at risk for falls and that the bed should have been left in the lowest position when unattended. The Director of Nursing also confirmed the expectation that the bed remain in the lowest position when staff are not present. This failure to follow established fall prevention protocols resulted in a deficiency related to accident hazards and inadequate supervision.
Failure to Administer Oxygen Therapy as Ordered by Physician
Penalty
Summary
The facility failed to administer oxygen therapy as ordered by physicians for three residents with significant respiratory and cardiac diagnoses. For one resident with chronic obstructive pulmonary disease (COPD), pulmonary candidiasis, and atrial fibrillation, physician orders specified oxygen at 5 liters per minute (LPM) via nasal cannula (NC), but observations showed the resident receiving oxygen at 3.5 LPM and, at another time, at 7 LPM. The LPN confirmed the flow rate was set incorrectly and adjusted it. Another resident with COPD and a cardiac defibrillator had an order for oxygen at 2 LPM via NC as needed for shortness of breath, but was observed receiving oxygen at 3.5 LPM and later at 4 LPM. The LPN confirmed the oxygen was not set per the physician's order. A third resident with multiple diagnoses, including endometrial cancer, heart failure, and dependence on supplemental oxygen, had an order for 4 LPM via NC, but was observed receiving 3.5 LPM. The DON and LPN both confirmed the oxygen was not set as ordered. Facility policy required medications and treatments, including oxygen, to be administered only as ordered by a licensed prescriber and for staff to verify and adjust oxygen flow rates according to physician orders. Despite these policies, staff did not consistently monitor or set oxygen flow rates as prescribed, as confirmed by direct observation, staff interviews, and record review. The DON stated that her expectation was for licensed nurses to monitor and ensure oxygen settings matched physician orders, but this was not consistently done.
Failure to Post Daily Nurse Staffing Information
Penalty
Summary
The facility failed to post daily nurse staffing information as required by its policy and federal regulations. According to the facility's policy, the number of nursing personnel responsible for direct care, including RNs, LPNs/LVNs, and CNAs, must be posted in a prominent location within two hours of each shift's start. Observations on two consecutive days revealed that the staffing posting was outdated, displaying information from several weeks prior. The posting was located in a clear glass case near the main dining area and had not been updated since the date indicated. Interviews with the interim DON, Human Resources Director, and Administrator confirmed that the daily Per Patient Daily Ratio (PPD) staffing information had not been posted since the last date observed. The interim DON was unaware of who was responsible for ensuring the daily posting, and both the Human Resources Director and Administrator acknowledged that the posting had not been updated as required. No information was provided regarding any specific residents affected or their medical conditions at the time of the deficiency.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Waynesboro
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Keysville Nursing Home & Rehab | 19.3 mi | ★★★★★ | 0 | 0 |
| Gracewood Nsg Facility(unit 9) | 20.1 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Bethany | 20.1 mi | ★★★★★ | 0 | 0 |
| Place At Deans Bridge, The | 23.5 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Old Capitol | 23.7 mi | ★★★★★ | 9 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.