Above average — CMS composite of the measures below.
The next survey window likely opens around February 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 Brantwood Nh & Retirement Center during CMS and state inspections, most recent first.
The facility identified a discrepancy in a hospice resident's liquid morphine and, after an audit and investigation, substantiated that a nurse had diverted 3.75 mL of morphine sulfate. The facility's policy required timely reporting of misappropriation of resident property, including to APS, and assigned responsibility for notifications to the Administrator or designee. Although the incident was reported to the State, law enforcement, DEA, and the Board of Nursing, APS was not notified, and the Administrator later acknowledged that this reporting requirement was missed.
A resident with advanced dementia on hospice care had PRN liquid Morphine ordered for pain and shortness of breath, initially at a higher dose and frequency that was later reduced after the physician observed excessive drowsiness. Over time, MARs showed frequent PRN Morphine administrations, primarily by one nurse, while hospice and nursing notes documented no pain or distress. A controlled substance count revealed that a portion of the Morphine supply was missing, and an audit found discrepancies between doses removed and doses documented as given, leading to a substantiated finding of drug diversion and misappropriation of the resident’s controlled medication.
The facility failed to maintain cleanliness in the kitchen, with observations of food particles, grease buildup, and dust in food preparation areas. Interviews revealed a lack of awareness and adherence to cleaning protocols among staff, with the Nutritional Service Director and Dietary Service Manager acknowledging the issues. The Administrator confirmed that the expected cleaning protocols were not followed.
Expired medications, including Insulin Novolog and Apresoline, were found in a medication cart, and expired Meropenem, Maxipime, and Insulin Semglee were found in a storage room refrigerator. Nurses failed to check expiration dates at the start of their shifts, contrary to the expectations set by the DON and Administrator.
Failure to Report Drug Diversion to Adult Protective Services
Penalty
Summary
The facility failed to report an allegation of misappropriation of resident property to Adult Protective Services (APS) as required by its own abuse, neglect, and misappropriation policy. The policy, last revised 12/12/25, stated that residents have the right to be free from abuse, including misappropriation of property, and defined misappropriation as the deliberate misplacement, exploitation, or wrongful use of a resident's belongings or money without consent. The policy required immediate reporting, but no later than 2 hours for allegations involving abuse or serious injury, and no later than 24 hours for other allegations, to specified agencies including the State Survey Agency and APS. The Administrator or designee was responsible for ensuring all required agencies were notified. Record review showed that on 4/1/25 at 2:00 PM the facility became aware of a discrepancy involving a resident's liquid morphine, and an audit that same day identified missing narcotics. An investigation was initiated, and a nurse was identified as the suspected staff member and suspended pending investigation. The investigation, completed on 4/9/25, substantiated diversion of the resident's medication and identified the nurse as responsible, with 3.75 mL of morphine sulfate determined to be missing. The facility notified law enforcement, the Drug Enforcement Agency, the State Agency, and the Board of Nursing; however, the Investigation Report indicated APS/Department of Social Services were not notified. In interview, the Administrator acknowledged that the discrepancy was initially thought to be a calculation error, that the resident was under hospice care and did not experience treatment interruption, and that she missed reporting the diversion of a resident drug to APS.
Misappropriation of Controlled Medication Through Drug Diversion
Penalty
Summary
The deficiency involves the facility’s failure to protect a resident’s right to be free from misappropriation of property, specifically controlled medication (liquid Morphine). The resident, who had advanced dementia and was enrolled in hospice, had physician orders for Morphine concentrate 20 mg/mL, initially at 0.5 mL by mouth every hour as needed for shortness of breath or pain, later changed to 0.25 mL every 4 hours as needed after the physician observed the resident was very drowsy. The March Medication Administration Record (MAR) showed multiple administrations of 0.5 mL Morphine on various dates by two nurses, and later 0.25 mL doses primarily by one nurse. The controlled substance count record indicated the pharmacy supplied a 30 mL Morphine solution, and on one date a nurse documented withdrawing 0.25 mL with 13.5 mL remaining in the bottle. Review of hospice notes from mid-March to early April documented that the resident was not in distress and did not report pain, and there were no nursing notes during that period indicating the resident was in pain or discomfort. Despite this, the MAR reflected frequent PRN Morphine administrations, particularly by one nurse, and an unusually high administration frequency compared to other nurses. An audit of the controlled substance records identified discrepancies between the doses logged out and the doses documented as administered to the resident, resulting in a determination that 3.75 mL of Morphine was missing. The facility’s investigation substantiated drug diversion and identified one nurse as responsible based on the pattern of administration and documentation discrepancies. The facility became aware of a discrepancy involving the resident’s liquid Morphine when a nurse noticed an issue with the controlled substance count sheet and reported it as a possible mathematical error at the end of her shift. The DON initially believed the discrepancy was due to incorrect math but, upon further review of the documentation and signatures on the controlled substance count sheets, recognized an actual discrepancy in addition to calculation errors. The DON noted that one nurse had frequently administered the Morphine and was the last to administer it, while another nurse had possession of the keys when the discrepancy was first noticed but did not report it immediately. The Administrator and Medical Director were informed of the missing Morphine and the suspected drug diversion, and the Medical Director assessed the resident and found no documented negative outcomes, but the core deficiency remained the misappropriation of the resident’s controlled medication as evidenced by the missing 3.75 mL of Morphine and the documented discrepancies.
Deficiency in Kitchen Cleanliness and Maintenance
Penalty
Summary
The facility failed to maintain cleanliness in the food preparation and service areas, as observed during a kitchen tour. The 6-compartment steam table had floating food particles in standing water, with lids encrusted with dried food and grease. The reach-in refrigerators contained leftover food and dried liquids from previous meals, while meal carts and plate warmers were found with dried food crumbs, meat products, and liquid spills. Additionally, ceiling vents and air conditioning units had significant dust and debris, potentially affecting food safety. Interviews with dietary aides revealed a lack of awareness regarding cleaning schedules and responsibilities. The Nutritional Service Director confirmed the observations and acknowledged the absence of a specific sign-off process for cleaning tasks. The Dietary Service Manager admitted awareness of the cleaning issues and mentioned plans to develop a comprehensive cleaning list. The Administrator stated that the Dietary Manager and Nutritional Service Director were responsible for maintaining kitchen cleanliness, but the expected protocols were not followed.
Expired Medications Found in Medication Cart and Storage Room
Penalty
Summary
The facility failed to remove expired medications from a medication administration cart and a medication storage room, as observed during a survey. On the 200 hall medication cart, a multi-dose vial of Insulin Novolog, opened on November 5, 2024, was found, which should have been discarded by December 3, 2024, according to the manufacturer's guidelines. Additionally, a blister card of Apresoline 25 mg with five tablets expired on November 29, 2024, was also present. Nurse #1, responsible for the cart, admitted to not checking the expiration dates at the beginning of her shift and confirmed that she did not administer the expired insulin during her shift. The Director of Nursing (DON) stated that nurses were expected to check and remove expired medications every shift. In the medication storage room refrigerator, four opened plastic bags of Meropenem, expired on December 15, 2024, and three opened plastic bags of Maxipime, expired on December 9, 2024, were found. Additionally, two sealed multi-dose vials of Insulin Semglee, expired in November 2024, were present. Nurse #5 acknowledged not checking the expiration dates at the start of her shift. The DON reiterated that all nurses were responsible for ensuring no expired medications remained in storage. The Administrator also expected no expired items to be left in medication carts or storage rooms.
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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 Oxford
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oxford Health And Rehabilitation Center | 0.2 mi | ★★★★★ | 14 | 0 |
| Senior Citizens Home | 7.8 mi | ★★★★★ | 3 | 0 |
| Kerr Lake Nursing And Rehabilitation Center | 9.9 mi | ★★★★★ | 2 | 0 |
| Camellia Gardens Center For Nursing And Rehab | 9.9 mi | ★★★★★ | 7 | 1 |
| Clarksville Health & Rehab Center | 20.4 mi | ★★★★★ | 0 | 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.