Above average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Rehabilitation And Healthcare Ctr (the) during CMS and state inspections, most recent first.
A facility failed to maintain a medication error rate below 5%, resulting in a 15.38% error rate. Errors included incorrect dosing of Vitamin D3, administering the wrong medication and incorrect dosing of Psyllium, and administering Sevelamer Carbonate after a meal instead of with it. These errors affected three cognitively intact residents, as confirmed by the nursing staff and DON.
The facility failed to maintain accurate medical records for four residents, leading to deficiencies in care. A resident's treatment for a toe wound was not documented correctly, another resident's cast care was inaccurately recorded after the cast was removed, a third resident's blood pressure was not consistently documented before administering medication, and a fourth resident's blood pressure was incorrectly recorded on a restricted arm. Interviews confirmed these documentation errors.
A resident with intact cognition was observed exposed in their room, visible from the hallway, on two consecutive mornings. Despite numerous staff members passing by, no action was taken to cover the resident or close the door, violating the facility's dignity policy. Interviews with staff confirmed the expectation to maintain resident privacy and dignity.
A resident with PTSD and other conditions reported staff sleeping during night shifts, but the facility failed to file a grievance despite being aware of the complaint. Interviews with staff, including the Administrator and DON, confirmed awareness of the issue, yet no formal grievance was documented, violating the resident's rights.
The facility failed to implement physician orders for three residents, including not completing a prescribed toe treatment, lacking a physician order for a boot immobilizer, and not obtaining weekly weights. Observations and interviews confirmed these deficiencies, highlighting lapses in care and documentation.
A facility failed to follow physician orders for daily weights and notify a physician of a significant weight gain for a resident with liver cirrhosis. The resident experienced a 12.2 lb weight gain over four days, but weights were not recorded on three days, and the weight gain was not reported to the nurse practitioner. The facility's policy required confirmation and reporting of significant weight changes, which was not adhered to.
A facility failed to implement necessary interventions for a resident with severe cognitive impairment and pressure ulcers. Despite the care plan requiring an air mattress and Prevalon boots, observations showed the resident on a standard mattress without the prescribed equipment. Staff interviews revealed a lack of awareness and implementation of the care plan, which was confirmed by the unit manager and DON.
A resident with severe cognitive impairments and significant weight loss was not assessed by the dietitian for further interventions, despite facility policy requiring such action. The resident lost 7.25% of their weight in one month, but the dietitian was not informed, and the Director of Nursing was unaware of the weight loss, leading to a lack of timely dietary interventions.
The facility failed to maintain proper care of PICC lines for two residents, resulting in deficiencies in intravenous therapy administration. One resident's dressing was obscured by gauze, preventing site visualization, while another's dressing was lifting and not changed as required. The facility's policy was not followed, and documentation discrepancies were noted.
A resident received Vancomycin four times daily instead of the prescribed twice daily due to a failure to discontinue an original order when a new order for a different brand was obtained. This error was identified through record reviews and staff interviews, confirming the administration of both Vancomycin HCl Oral Suspension and Firvanq Oral Solution concurrently.
The Foodservice Director (FSD) failed to follow proper food handling practices, leading to potential contamination. The FSD was observed touching a garbage can lid with bare hands and then handling resident meal trays without washing her hands. Despite acknowledging the need for hand hygiene, the FSD did not wash her hands until later in the process.
The facility failed to ensure proper disinfection of shared resident equipment, as observed with two nurses during medication passes. One nurse used a blood pressure cuff and pulse oximeter on multiple residents without disinfecting them between uses, while another nurse did not sanitize a blood pressure cuff before or after use. This was contrary to facility policy and CDC guidelines, as confirmed by management.
Medication Errors Exceeding 5% in LTC Facility
Penalty
Summary
The facility failed to maintain a medication error rate below 5%, resulting in a rate of 15.38% during the survey. This was due to errors made by three out of four nurses observed, affecting three residents. For one resident, a nurse administered an incorrect dose of Vitamin D3, giving 5000 units instead of the prescribed 1000 units. This resident was cognitively intact, as indicated by a BIMS score of 15 out of 15. Another resident was affected when a nurse administered the wrong medication, Banatrol Plus instead of Juven, and failed to measure the correct dose of Psyllium. The nurse mistakenly believed a heaping teaspoon was equivalent to the prescribed 3.4 grams. The medication packets were stored incorrectly, contributing to the error. This resident was also cognitively intact, with a BIMS score of 13 out of 15. A third resident received their medication, Sevelamer Carbonate, after a meal instead of with it, as per the physician's order. The medication was administered 1 hour and 20 minutes late, after the resident had finished dinner. This resident, too, was cognitively intact, with a BIMS score of 15 out of 15. The errors were acknowledged by the nursing staff and the Director of Nursing, who confirmed the deviations from the prescribed medication administration protocols.
Inaccurate Medical Record Documentation
Penalty
Summary
The facility failed to maintain accurate medical records for four residents, leading to deficiencies in care. For Resident #44, the facility did not accurately document the completion of a physician-ordered treatment for the resident's left great toe. Despite the treatment being recorded as administered on the Treatment Administration Record (TAR), observations and interviews revealed that the dressing was not applied as ordered, and the resident confirmed infrequent dressing changes. Resident #80's records inaccurately documented cast care, even though the cast had been removed weeks prior. The Treatment Administration Record continued to show that cast care was being signed off, despite the absence of a cast. Interviews with nursing staff confirmed that the order was not updated, and the documentation was incorrect. For Resident #106, the facility failed to ensure that blood pressure readings were consistently documented before administering midodrine, as required by the physician's order. The Medication Administration Record indicated the medication was given, but there was a lack of corresponding blood pressure documentation. Additionally, Resident #115's records inaccurately documented blood pressure readings taken on the right arm, despite orders prohibiting such due to the presence of an arteriovenous fistula. Interviews confirmed these inaccuracies in documentation.
Resident Privacy and Dignity Violation
Penalty
Summary
The facility failed to provide a dignified existence for a resident diagnosed with Bipolar disorder and personality disorder, who had intact cognition as indicated by a perfect score on the Brief Interview for Mental Status. The deficiency was observed when the resident was found sleeping in their bed, visible from the hallway with the bedroom door open, wearing only briefs, and later completely naked. This exposure occurred on two consecutive mornings, with numerous staff members walking past the room without intervening to cover the resident or close the door. The facility's policy on dignity, revised in February 2021, emphasizes that residents should be treated with dignity and respect at all times. However, the lack of a privacy curtain and the staff's inaction in addressing the resident's exposure violated this policy. Interviews with a nurse and the Director of Nursing confirmed that staff should have intervened to maintain the resident's privacy and dignity, acknowledging the failure to do so in this instance.
Failure to File Grievance for Resident's Complaint
Penalty
Summary
The facility failed to file a grievance for a resident who expressed a complaint about staff sleeping during the night shift. The resident, who was admitted with diagnoses including diabetes, anxiety, and post-traumatic stress disorder, was cognitively intact and reported that staff were 'horrendous' and took a long time to respond to call bells. The resident also mentioned having photos of staff members sleeping during the night shift. Despite these complaints, the facility's grievance log did not include any documentation of a grievance being filed on behalf of the resident. Interviews with various staff members, including the Administrator, Nurse #8, Unit Manager #1, the Social Worker, and the Director of Nursing (DON), revealed that they were all aware of the resident's complaints. The Social Worker had informed both the Administrator and the DON about the complaints and stated that a grievance should have been completed. However, the Administrator admitted to not completing a grievance, and the DON confirmed that either the Social Worker or the Administrator was responsible for filing grievances. The facility's policy on grievances clearly outlines the process for filing and investigating grievances, including the role of the Administrator as the grievance officer. Despite this policy, the facility failed to adhere to its procedures, resulting in the resident's complaint not being formally addressed. The lack of action in filing a grievance represents a failure to honor the resident's right to voice grievances without discrimination or reprisal, as required by the facility's policy.
Failure to Implement Physician Orders and Document Care
Penalty
Summary
The facility failed to implement physician orders for three residents, leading to deficiencies in care. For one resident, the facility did not complete a prescribed treatment for the left great toe, which involved a normal saline wash, application of bacitracin, and covering with a dry protective dressing every evening. Observations on consecutive days revealed the absence of the dressing, and the resident confirmed that the dressing was changed infrequently. The Director of Nurses acknowledged that staff should be completing physician's orders. Another resident was observed without a boot immobilizer, which was supposed to be worn at all times except during hygiene and exercises, according to an orthopedic consult. However, there was no physician order for the boot immobilizer in the resident's records. Interviews with nursing staff and management confirmed the absence of a necessary order for the boot immobilizer, indicating a lapse in obtaining and documenting physician orders. Additionally, the facility failed to obtain weekly weights for two residents as per physician orders. One resident's records showed missed weight documentation on several occasions, and there was no indication of refusal by the resident. Similarly, another resident's records indicated signed-off weights without actual documentation, despite a noted weight loss over six weeks. The Director of Nurses confirmed that nursing staff should be following physician orders and documenting weights in the electronic medical record.
Failure to Monitor and Report Significant Weight Gain
Penalty
Summary
The facility failed to provide treatment and care in accordance with professional standards of practice for a resident with liver cirrhosis. The resident was admitted with diagnoses including chronic kidney disease, cirrhosis, and edema, and had physician orders for daily weights due to the risk of significant weight gain. Despite these orders, the facility did not obtain daily weights on several days and failed to notify a physician or nurse practitioner of a significant weight gain of 12.2 lbs over four days. The resident's weight was not recorded on three consecutive days, and there was no documentation of the resident refusing to be weighed or any attempts to re-weigh the resident to confirm the weight gain. The nurse practitioner, who examined the resident, was not informed of the potential significant weight gain or the resident's refusal to be weighed. The facility's policy required that any weight change of 5% or more be confirmed and reported to the dietitian, but this was not done. The medical record lacked evidence of practitioner notification regarding the weight gain, and the weight was only confirmed after the surveyor's interview. The Director of Nurses acknowledged that the weight should have been confirmed and reported as per the physician's orders.
Failure to Implement Pressure Ulcer Interventions
Penalty
Summary
The facility failed to implement necessary interventions for pressure ulcer care for Resident #119, who was admitted with severe cognitive impairment, dementia, severe protein malnutrition, and failure to thrive. The resident was assessed as being at risk for skin breakdown and had two unstageable pressure ulcers. The care plan for Resident #119 included the use of an air mattress and Prevalon boots to prevent further skin breakdown and aid in healing. However, observations over several days revealed that the resident was on a standard mattress without the prescribed air mattress, and there were no Prevalon boots in the room. Interviews with staff, including a CNA, a nurse, and the unit manager, confirmed that the interventions outlined in the care plan were not being followed. The CNA and nurse were unaware of the requirement for an air mattress and Prevalon boots, and the unit manager acknowledged that these interventions should have been provided. The Director of Nursing also confirmed that the interventions in the care plan should have been implemented to support wound healing for Resident #119.
Failure to Address Significant Weight Loss in Resident
Penalty
Summary
The facility failed to adequately maintain the nutrition and hydration status of a resident who experienced significant weight loss. The resident, admitted with diagnoses including major depressive disorder, asthma, and muscle weakness, showed a weight loss of 7.25% over one month. Despite the facility's policy requiring immediate notification to the dietitian for any weight change of 5% or more, the resident was not assessed by the dietitian for further interventions. The last dietitian assessment was conducted months prior, and no recent progress notes were available. Interviews revealed a lack of communication and awareness among staff regarding the resident's weight loss. The dietitian, new to the facility, was unsure if she had been informed about the resident's condition, while the Director of Nursing was under the impression that the resident was gaining weight. This miscommunication and oversight resulted in the resident not receiving timely dietary interventions, as required by the facility's policy.
Deficiencies in PICC Line Care and Maintenance
Penalty
Summary
The facility failed to provide proper care and maintenance of Peripherally Inserted Central Catheters (PICC) for two residents, leading to deficiencies in the administration of intravenous therapy. For one resident, the facility did not change the PICC line dressing as ordered, and the dressing was obscured by gauze, preventing visualization of the insertion site. The nurse responsible for the dressing change did not obtain measurements and used gauze under the transparent dressing, which was against the facility's policy. The Unit Manager and Director of Nursing confirmed that the dressing should not have gauze underneath and should allow for visualization of the insertion site. For the second resident, the facility failed to change or reinforce a PICC line dressing that was lifting at the edge, compromising its integrity. The dressing was observed to be lifting on multiple occasions, and the insertion site was not visible due to a medicated patch. Although the Medication Administration Record indicated that the dressing was changed, observations showed it was not. The LPN involved stated that he did not change the dressing and would notify a Registered Nurse if a dressing was lifting, as he was not authorized to change PICC line dressings. The Director of Nursing acknowledged that a lifting PICC line dressing should be changed or reinforced and that the facility's policy is to change the dressing weekly. The report highlights the failure to adhere to professional standards of practice for PICC line care, as evidenced by the lack of proper dressing changes and documentation discrepancies.
Medication Error Due to Duplicate Vancomycin Orders
Penalty
Summary
The facility failed to ensure that a resident was free from significant medication errors. The resident, who was cognitively intact and admitted with diagnoses including enterocolitis due to clostridium difficile, was prescribed Vancomycin to be administered twice daily for seven days, followed by once daily for another seven days. However, due to an insurance issue, the original Vancomycin HCl Oral Suspension was not covered, and a new order for Firvanq Oral Solution was obtained. This resulted in both medications being administered concurrently, leading to the resident receiving Vancomycin four times daily instead of the prescribed two times daily. The error was identified through a review of the resident's Medication Administration Record and confirmed through interviews with nursing staff and the Nurse Practitioner. The Unit Manager acknowledged that the nurse should have discontinued the original Vancomycin order when the new Firvanq order was placed. The Director of Nursing confirmed that administering Vancomycin four times daily constituted a medication error, as the resident was only supposed to receive it twice daily.
Improper Food Handling Practices Observed
Penalty
Summary
The facility failed to adhere to proper food handling practices, increasing the risk of foodborne illness. During a lunch tray line service, the Foodservice Director (FSD) was observed wearing gloves while making a sandwich. After removing her gloves, she touched the lid of a garbage can with her bare hands, contaminating them. She then handled multiple resident meal trays with these contaminated hands. The FSD continued to touch various surfaces, including the handle of a walk-in refrigerator and a cup placed on a resident's tray, without washing her hands. It was only after retrieving food from the oven that the FSD washed her hands. In an interview, the FSD acknowledged the need for handwashing when leaving stations, changing gloves, and after contamination, but admitted she failed to do so during the observed incident.
Inadequate Disinfection of Shared Equipment
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, as evidenced by the actions of Nurse #6 and Nurse #9. During a medication pass, Nurse #6 was observed using a blood pressure cuff and a fingertip pulse oximeter on three different residents without disinfecting the equipment between uses. Nurse #6 admitted to cleaning the vital signs machine only at the end of her shift, contrary to the facility's policy and CDC recommendations, which require disinfection between each resident use. Unit Manager #1 confirmed that Nurse #6 should have cleaned the equipment between each resident. Similarly, Nurse #9 was observed checking a resident's blood pressure with a portable cuff without sanitizing it before or after use. The Director of Nursing confirmed that the nursing staff is expected to clean the vital sign machine between each resident. These observations indicate a failure to adhere to the facility's policy and CDC guidelines for disinfection of non-critical resident-care items, potentially increasing the risk of communicable disease transmission.
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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 Danvers
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Twin Oaks Center | 1 mi | ★★★★★ | 0 | 0 |
| New England Homes For The Deaf, Inc | 1.3 mi | ★★★★★ | 0 | 0 |
| Hunt Nursing & Rehab Center | 1.4 mi | ★★★★★ | 21 | 0 |
| Care One At Peabody | 1.8 mi | ★★★★★ | 10 | 0 |
| Ledgewood Rehabilitation And Nursing Center | 2.4 mi | ★★★★★ | 1 | 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.