Above average — CMS composite of the measures below.
A standard survey is most likely before around October 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 Care Center during CMS and state inspections, most recent first.
The facility did not establish or maintain an infection prevention and control program as required, resulting in a deficiency identified by surveyors.
Two residents with documented level two PASRR determinations for serious mental illness or developmental disability were incorrectly coded on their MDS 3.0 assessments as not having such conditions, despite supporting documentation in their records. These inaccuracies were confirmed by a social worker.
A CNA at a facility inadvertently live-streamed a video from a resident's room using a social media app, violating privacy policies. The resident, with severe cognitive impairment, was in the background but not exposed or demeaned. The facility's policy prohibits personal cell phone use in working areas, and the incident was reported by a housekeeper after a community person saw the live feed.
A facility failed to protect two residents from sexual abuse by another resident with a history of inappropriate behavior. Despite incidents involving a resident with severe cognitive impairment and another with dementia, the facility did not document the incidents, conduct thorough investigations, or report them to the State agency. The care plan for the resident with inappropriate behavior lacked interventions to prevent such incidents, and the facility's policy on abuse prevention was not followed.
A resident with severe cognitive impairment was not reported to her physician or family after being sexually abused by another resident. The incident was not documented in her medical records, and staff failed to notify the family or physician, despite the facility's policy requiring such notification. The deficiency was identified during an investigation.
The facility failed to implement its abuse prohibition policy after allegations of abuse involving two residents. A resident with severe cognitive impairment was reportedly inappropriately touched by another resident, but there was no documentation or thorough investigation. Similarly, another resident was involved in an incident with the same perpetrator, which was also not documented or reported. The facility's policy requires immediate investigation and reporting, which was not followed, resulting in non-compliance.
The facility failed to report and investigate allegations of sexual abuse involving two residents. A resident with severe cognitive impairment was allegedly inappropriately touched by another resident, but the incident was not documented or reported to the State agency. Another resident was also involved in an incident with the same resident, which was not documented or assessed. The facility's policy requires immediate reporting of such incidents, but this was not followed.
The facility failed to investigate allegations of resident-to-resident sexual abuse involving two residents with cognitive impairments. Despite staff witnessing or being informed of inappropriate touching by another resident, there was no documentation or assessment in the affected residents' medical records. The DON did not report or thoroughly investigate the incidents, believing they were not abuse. Additionally, the resident responsible for the behavior did not have a care plan addressing inappropriate sexual behavior, contributing to the deficiency.
A facility failed to develop a comprehensive care plan for a resident's IV medication. Despite a physician's order for IV Zosyn to treat atelectasis, the care plan did not address this need. An LPN confirmed the omission, indicating a deficiency in care planning.
Failure to Implement Infection Prevention and Control Program
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program. This deficiency was identified during the survey process, indicating that the required measures to prevent and control infections were not established or maintained as per regulatory standards. The report notes the absence of a comprehensive infection prevention and control program but does not provide further details regarding specific actions, inactions, or events, nor does it mention any particular residents or staff involved.
Inaccurate PASRR Coding on MDS Assessments
Penalty
Summary
The facility failed to accurately code the Pre-Admission Screening and Resident Review (PASRR) status on the Minimum Data Set (MDS) 3.0 assessments for two residents. Record review showed that one resident was admitted with diagnoses including bipolar disorder, schizophrenia, and depression, and had a level two PASRR assessment from the state agency indicating a serious mental illness. However, the most recent comprehensive MDS 3.0 assessment for this resident was incorrectly coded as not having a serious mental illness or intellectual disability according to the PASRR process. Similarly, another resident was admitted with diagnoses including cerebral palsy, epilepsy, and anxiety disorder, and had a level two PASRR assessment from the state agency indicating a developmental disability. The most recent comprehensive MDS 3.0 assessment for this resident was also incorrectly coded as not having a serious mental illness or intellectual disability. These coding inaccuracies were verified by a social worker during an interview.
Unauthorized Video Recording of Resident
Penalty
Summary
The facility failed to ensure the privacy and confidentiality of a resident's personal and medical records by allowing unauthorized video recordings by staff. A self-reported incident revealed that a Certified Nursing Assistant (CNA) inadvertently live-streamed a video from a resident's room using a social media application called Tagged. The incident was reported by a housekeeper after a community person informed her about the live feed. The CNA was identified in the video, and although the resident was not exposed or demeaned, the act violated the facility's privacy policies. The resident involved, identified as Resident #4, had a medical history including Alzheimer's disease, type II diabetes, dementia with behavioral disturbances, depression, anxiety, and adult failure to thrive. The resident required substantial assistance with daily activities and had severe cognitive impairment. During the incident, the resident was in the background of the video while the CNA was providing care. The facility's investigation included interviews with staff and the community person who reported the incident, but the video was not viewed by anyone at the facility except the community person. The facility's policy prohibits the use of personal cell phones in working areas and strictly forbids taking pictures or videos of residents for personal use or social media. Despite the CNA's claim that the video was not saved or posted, the act of live-streaming from the resident's room without consent constituted a breach of privacy. The facility determined the allegation of abuse to be unsubstantiated but disciplined the CNA for violating privacy policies.
Failure to Protect Residents from Sexual Abuse
Penalty
Summary
The facility failed to protect two residents from sexual abuse by another resident, leading to a deficiency in ensuring resident safety. Resident #50, who had severe cognitive impairment and was diagnosed with Parkinson's disease, dementia, and anxiety disorder, was subjected to an incident of sexual abuse by Resident #101. Resident #101, who had a history of sexually inappropriate behaviors, placed his hand down Resident #50's incontinence brief. This incident was witnessed by staff members, but there was no documentation of the incident in Resident #50's medical record, nor was there evidence of an assessment or follow-up after the incident. Additionally, Resident #6, who had dementia and anxiety disorder, was also involved in an incident with Resident #101. Resident #101 attempted to grab Resident #6 by his pants, but this incident was not reported to the State agency, and no thorough investigation was conducted. The medical record for Resident #6 did not document the incident or include an assessment afterward. Despite Resident #101's history of inappropriate behavior, his care plan did not include interventions to address or prevent such behaviors. The Director of Nursing (DON) was informed of both incidents but did not consider them as abuse, leading to a lack of thorough investigation and reporting. The facility's policy on abuse, neglect, and exploitation was not followed, as it required the development and implementation of procedures to prevent abuse. The failure to address Resident #101's behaviors and protect other residents from harm resulted in non-compliance with the facility's policies and state regulations.
Failure to Report Change in Condition After Resident Abuse
Penalty
Summary
The facility failed to report a change in condition for a resident who was sexually abused and exhibited signs of distress. The resident, who had severe cognitive impairment due to Parkinson's disease, dementia, and anxiety disorder, was not reported to her physician or family after an incident where another resident attempted inappropriate contact. The incident was not documented in the resident's medical records, and there was no evidence of an assessment or follow-up after the event. The incident was discovered when the resident's daughter noticed her mother was agitated and contacted the police. Interviews with staff revealed that the incident occurred when a male resident attempted to touch the female resident inappropriately. Staff intervened, but the incident was not communicated to the resident's family or physician, nor was it documented in the medical records. The Director of Nursing confirmed that the nursing staff should have notified the physician and family about the change in the resident's condition. The facility's policy on notification of changes, which requires prompt communication with the resident, physician, and representative, was not followed. This deficiency was investigated under a specific complaint number.
Failure to Implement Abuse Prohibition Policy
Penalty
Summary
The facility failed to implement its abuse prohibition policy following allegations of abuse involving two residents. Resident #50, who was admitted with severe cognitive impairment, was reportedly inappropriately touched by another resident, Resident #101. Despite multiple staff members witnessing or being informed of the incident, there was no documentation in Resident #50's medical record regarding the incident, nor was there evidence of a thorough investigation or reporting to the State agency. The Director of Nursing (DON) was aware of the incident but did not consider it abuse and thus did not conduct a thorough investigation or report it. Similarly, Resident #6, who also had cognitive impairments, was involved in an incident where Resident #101 attempted to grab him inappropriately. This incident was also not documented in Resident #6's medical record, and no assessment was conducted post-incident. The DON was informed of this incident but did not report it to the State agency, as she did not perceive it as abuse. Resident #101's care plan lacked interventions to address inappropriate sexual behavior, despite previous incidents of similar behavior being documented. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and reporting of such incidents, which was not adhered to in these cases. The policy outlines the need for protection of residents, thorough documentation, and reporting to relevant authorities, none of which were followed. The failure to implement these procedures resulted in non-compliance with the facility's own policies and state regulations, as evidenced by the lack of investigation and reporting of the incidents involving Residents #50 and #6.
Failure to Report and Investigate Allegations of Sexual Abuse
Penalty
Summary
The facility failed to timely report allegations of sexual abuse involving two residents to the Administrator and State agency. Resident #50, who was admitted with severe cognitive impairment, was allegedly inappropriately touched by another resident, Resident #101. The incident was reported to the police by Resident #50's family, but there was no documentation in Resident #50's medical record regarding the incident or any follow-up assessment. Interviews with staff revealed conflicting accounts of the incident, and the Director of Nursing (DON) admitted to not conducting a thorough investigation or reporting the incident to the State agency, as she did not perceive it as abuse. Resident #6 was also involved in an incident with Resident #101, where Resident #101 attempted to grab Resident #6 by his pants. This incident was not documented in Resident #6's medical record, and no assessment was conducted afterward. The DON was informed of the incident but did not report it to the State agency, as she did not consider it abuse. Resident #101's care plan did not include interventions to address sexual abuse or inappropriate sexual behavior, despite previous incidents of similar behavior documented in his progress notes. The facility's policy on abuse, neglect, and exploitation requires immediate reporting of all alleged violations to the Administrator and State agency. However, the facility failed to adhere to this policy, as evidenced by the lack of timely reporting and investigation of the incidents involving Residents #50 and #6. The facility also did not provide evidence of any assessments or follow-up actions taken to address the incidents, highlighting a significant deficiency in their handling of abuse allegations.
Failure to Investigate Resident-to-Resident Abuse
Penalty
Summary
The facility failed to thoroughly investigate allegations of resident-to-resident sexual abuse involving two residents, Resident #6 and Resident #50. Resident #50, who was admitted with severe cognitive impairment, was reportedly inappropriately touched by another resident, Resident #101. Despite multiple staff members witnessing or being informed of the incident, there was no documentation in Resident #50's medical record regarding the incident, nor was there evidence of an assessment or follow-up. The Director of Nursing (DON) was informed of the incident but did not conduct a thorough investigation or report it to the State agency, as she did not consider it abuse. Resident #6, who also had cognitive impairments, was involved in a separate incident with Resident #101, where Resident #101 attempted to grab Resident #6 by his pants. This incident was also not documented in Resident #6's medical record, and no assessment was conducted. The DON was aware of this incident but similarly did not report it or investigate further, believing it was not abuse. Resident #101's care plan did not include interventions to address inappropriate sexual behavior, despite previous incidents of similar behavior being documented in his progress notes. The facility's policy on abuse, neglect, and exploitation requires immediate investigation and documentation of any suspected abuse, which was not followed in these cases. The lack of a comprehensive and individualized care plan for Resident #101 to prevent further incidents of sexual abuse or inappropriate behavior contributed to the deficiency. The facility's failure to adhere to its policies and procedures for investigating and documenting abuse allegations resulted in non-compliance with regulatory requirements.
Failure to Implement Comprehensive Care Plan for IV Medication
Penalty
Summary
The facility failed to develop and implement a comprehensive care plan for a resident's intravenous (IV) medication. The resident, who had intact cognition, was admitted with multiple diagnoses including a displaced intertrochanteric fracture of the right femur, rheumatoid arthritis, COPD, paroxysmal atrial fibrillation, chronic diastolic congestive heart failure, anxiety disorder, and depression. A physician's order dated 04/15/24 prescribed IV Zosyn to be administered every 6 hours for atelectasis. However, the current care plan dated 03/22/24 did not include any plan to address the resident's IV medication needs. An interview with an LPN confirmed the absence of a care plan for the resident's IV medication, highlighting a deficiency in the facility's care planning process for this resident.
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What surveyors actually found near you
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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 Sagamore Hills
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaks Of Brecksville | 2.1 mi | ★★★★★ | 0 | 0 |
| Northfield Village Retirement Community | 3.2 mi | ★★★★★ | 0 | 0 |
| Heights Rehabilitation And Healthcare Center, The | 3.5 mi | ★★★★★ | 3 | 0 |
| Aventura At Walton Hills | 3.9 mi | ★★★★★ | 21 | 0 |
| Avenue At Macedonia | 4.2 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.