Average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Somerfield At The Heritage during CMS and state inspections, most recent first.
A resident with cognitive impairment and limited mobility was transferred with a sit-to-stand lift by one CNA instead of the required 2-person assist. During the transfer, the resident slipped through the sling straps, fell backward, and hit her head on the bed. The resident was sent to the hospital and was diagnosed with a traumatic SAH, small SDH, and worsening intraparenchymal hemorrhage, after which the family chose comfort care and hospice.
Failure to Report Abuse and Misappropriation Allegations: The facility did not report multiple allegations involving suspected narcotic misappropriation and an altercation between two residents. Records showed severe cognitive impairment in the residents involved, and the DON stated the narcotic issue was not reported because the nurse claimed it was a documentation error and a drug test was negative. Staff interviews and documentation confirmed the resident-to-resident incident occurred, but it was also not reported.
Missed Indwelling Catheter Care for Two Residents: The facility failed to provide and document ordered catheter care for two residents with indwelling urinary catheters. One resident had severe cognitive impairment and the other had moderate cognitive impairment; both had physician-ordered or care-planned catheter care every shift with peri-area cleansing. The TARs showed numerous blank shifts across several months, and observations confirmed both catheters remained in place at bedside. The DON stated staff were expected to follow orders and that missed catheter care could lead to a UTI.
A resident with Alzheimer's Disease, anxiety, depression, and HTN had physician orders for Ensure, a fortified shake, and Pro-Stat oral liquid, but the MAR/TAR showed multiple missed or undocumented administrations over several months. The resident was severely cognitively impaired and identified as at risk for altered nutrition, while the DON confirmed staff should follow physician orders and that MARs/TARs were checked for blank spaces.
A resident with dementia, dry eye syndrome, and glaucoma had Latanoprost and artificial tears left unsecured and unattended on a nightstand in the resident’s room, despite not being care planned for self-administration. In a separate medication area, an unlocked controlled-medication box inside a medication refrigerator contained Ativan and lorazepam and was not permanently affixed or secured behind two locks, contrary to facility policy.
A facility failed to follow infection control practices during med pass, EBP, and catheter care. An RN picked up tablets that had fallen onto the med cart with bare hands and administered them to a resident, while a CNA did not perform hand hygiene between glove changes during catheter care. The facility also did not have EBP signage or PPE in place for residents with wounds, weeping edema, or an indwelling urinary catheter, and the DON confirmed those conditions required EBP.
Failure to Follow Two-Person Mechanical Lift Transfer Care Plan
Penalty
Summary
The facility failed to ensure the environment was free from accident hazards when staff did not follow the care plan requiring two-person assistance for transfers with a mechanical sit-to-stand lift. Resident #78, who was cognitively impaired and had impaired mobility, was dependent on staff for sit-to-stand and bed-to-chair transfers and had diagnoses including nonrheumatic aortic stenosis, major depressive disorder, and interstitial pulmonary disease. Her care plan identified a risk for falls related to mobility, gait, and balance deficits, and specifically required 2 CNAs to assist with transfers using the mechanical lift. On the day of the incident, a CNA transferred the resident using the sit-to-stand lift without another staff member present. While the CNA was pulling the resident’s pants down, the resident slipped through the sling straps, fell backward, and hit her head on the bed. The nurse later observed swelling to the back of the resident’s head and found her on the floor with her head against the metal part of the bed. The resident was sent to the hospital by EMS. The facility investigation, witness statements, and hospital records documented that the resident sustained a traumatic subarachnoid hemorrhage, small subdural hemorrhage, and later worsening intraparenchymal hemorrhage. The report states that the resident was admitted with a brain bleed and that the family chose comfort care and hospice. The CNA stated she had not known prior to the incident that two people were always required for use of the mechanical lift.
Failure to Report Abuse and Misappropriation Allegations
Penalty
Summary
The facility failed to report allegations of abuse and suspected misappropriation of resident property for multiple residents. Facility policies stated that suspected abuse, neglect, exploitation, misappropriation of resident property, or injury of unknown source must be reported immediately to the administrator and to other officials according to state law, and that covered individuals are required to report reasonable suspicion of a crime against a resident to law enforcement and the State Survey Agency within the required timeframes. Job descriptions for the LPN and DON also stated that suspicions of abuse, neglect, exploitation, or abandonment must be reported in accordance with state and federal regulations. For one allegation involving narcotic misappropriation, the facility received a report on 6/12/2025 regarding suspected misappropriation of narcotics for residents who were severely cognitively impaired and receiving hospice or palliative care. The investigation described discrepancies in narcotic sign-out documentation, including illegible dates, extra sign-outs beyond what was ordered, duplicate documentation of administration within a 30-minute period, and documentation of administration at a time when the nurse was not working. The DON stated the facility did not report the allegation because the nurse said it was a documentation error, audits were performed, and a drug test was negative, so the facility was unable to verify the allegation and did not report it to the State Agency. The facility also failed to report an incident in which one resident hit another resident on the back of the head after saying "sshh!" The resident who struck the other resident had severe cognitive impairment, with short- and long-term memory problems and inability to recognize season, room, or staff. The resident who was struck also had dementia and moderate cognitive impairment. The progress note, soft file, and interviews showed the incident occurred, but the DON initially stated there were no reportable incidents involving the resident and later could not recall the altercation between the two residents. LPN D confirmed the incident involved the two residents and stated it was not reported.
Missed Indwelling Catheter Care for Two Residents
Penalty
Summary
The facility failed to provide indwelling urinary catheter care as ordered for two residents. Facility policy titled, Catheter Care, Urinary, dated August 2022, stated the purpose of the procedure was to prevent urinary catheter-associated complications, including urinary tract infections, and that catheter care should be recorded in the resident’s medical record with the date, time, and name and title of the person providing the care. Resident #23 was admitted with diagnoses including Insomnia, Neuromuscular Dysfunction of Bladder, and Hypertension. The quarterly MDS showed a BIMS score of 00, indicating severe cognitive impairment, and the resident had an indwelling urinary catheter. The care plan directed catheter care per policy, and the TAR ordered catheter care every shift with cleaning of the peri-area and output documentation. The TAR showed multiple missed documentation entries across April, May, and June 2026, including numerous day, evening, and night shifts. During observation on 6/10/2026 at 8:34 AM, the resident’s catheter bag was seen hanging at bedside with amber-colored urine. Resident #49 was admitted with diagnoses including Benign Prostatic Hyperplasia with Lower Urinary Tract Symptoms, Neurogenic Bladder, and Chronic Kidney Disease. The significant change MDS showed a BIMS score of 10, indicating moderate cognitive impairment, and the resident had an indwelling urinary catheter. A physician order dated 3/30/2026 directed catheter care every shift and cleaning of the peri-area. The TAR showed multiple missed documentation entries in April, May, and June 2026 across day, evening, and night shifts. Observations on 6/8/2026 and 6/9/2026 showed the catheter draining clear, yellow urine to a bedside bag with a dignity cover. During interview, the DON stated staff were expected to follow physician orders, there should not be blanks on the TAR where catheter care should be documented, staff were expected to provide catheter care, and failure to provide catheter care could result in a resident developing a UTI.
Missed Documentation and Administration of Ordered Nutritional Supplements
Penalty
Summary
The facility failed to follow physician orders for nutritional supplements for one resident who was admitted with diagnoses including Alzheimer's Disease, Anxiety, Depression, and Hypertension. The resident's record showed orders to provide and encourage Ensure three times a day, a fortified shake at all meals, and Pro-Stat oral liquid twice a day. The quarterly MDS indicated the resident was severely cognitively impaired and rarely or never understood, and the care plan identified the resident as at risk for altered nutrition and directed nutritional supplementation or fortified foods as ordered for additional calories and protein. Review of the MAR/TAR showed multiple missed or undocumented administrations of the ordered supplements across March, April, and May 2026. The facility failed to provide and document Ensure, fortified shake, and Pro-Stat oral liquid at the ordered times on numerous dates, including repeated omissions of Pro-Stat oral liquid in March and April, and missed administrations of all three supplements in May. During interview, the DON stated staff should follow physician orders and that MARs and TARs were spot checked for blank spaces, and confirmed that nutritional supplements should be provided as ordered by the physician.
Unsecured Medications Found in Resident Room and Medication Refrigerator
Penalty
Summary
The facility failed to ensure medications were properly stored and secured when medications were found unattended in a resident-occupied room and when controlled medications were stored unsecured in a medication refrigerator area. Facility policy stated that medications and biologicals are to be stored in locked compartments and that controlled substances are to be separately locked in permanently affixed compartments. In the Monarch medication room, an unlocked and unsecured controlled medication box was observed inside a medication refrigerator without a lock, containing one unopened 30 mL bottle of Ativan 2 mg/mL and two unopened 1 mL vials of lorazepam 2 mg/mL. The box remained unsecured during a later observation, and the DON acknowledged it was not locked and could be easily removed. Resident #42 was admitted with diagnoses including dementia, dry eye syndrome, and glaucoma, and the quarterly MDS showed a BIMS score of 12, indicating moderate cognitive impairment. Physician orders included Latanoprost ophthalmic solution for glaucoma and Refresh Tears ophthalmic solution as needed for dry eyes, and the care plan did not address self-administration of eye drops. In the resident's room, a bottle of Latanoprost eye drops and a bottle of carboxymethylcellulose 0.5% eye drops were observed sitting on the nightstand, unsecured and unattended. RN A stated medications should not be left unsecured in a resident's room, and the DON also stated that unattended and unsecured medications should not be left in a resident's room.
Infection Control Failures During Medication Administration, EBP, and Catheter Care
Penalty
Summary
The facility failed to provide and implement an infection prevention and control program when staff did not follow infection control practices during medication administration, Enhanced Barrier Precautions (EBP), and indwelling urinary catheter care. Facility policies reviewed stated that EBP are used for residents with wounds and/or indwelling medical devices, that signs are posted outside resident rooms indicating required PPE, and that hand hygiene is required after glove removal. The medication administration policy also required staff to follow established infection control procedures. During medication administration for one resident with diagnoses including urinary tract infection, mild cognitive impairment, hypertension, anemia, anxiety, depression, and hallucinations, an RN sanitized her hands, prepared multiple medications, and when three tablets fell onto the top of the medication cart, she picked them up with bare hands and placed them in a medication cup with the other medications. The cart top had not been cleaned and there was no clean barrier in use. The RN then administered the medications to the resident. When questioned, the RN stated her hands were clean and that staff wipe the medication cart each shift. The DON later stated that medications dropped on top of a medication cart should not be administered and should not be picked up with bare hands. The facility also did not implement EBP for residents with wounds or an indwelling urinary catheter. One resident had an open lesion on the right ankle and left lower leg weeping edema, with physician orders for wound care, but the physician orders, care plan, and room observations did not reflect EBP and no EBP signage or PPE were present outside the room. Another resident had an indwelling urinary catheter with catheter care ordered every shift, but the physician orders and care plan did not reflect EBP and no EBP signage or PPE were present outside the room. During catheter care, a CNA failed to perform hand hygiene between glove changes. The DON stated that residents with indwelling urinary catheters, weeping ulcers, weeping edema, and chronic wounds should have EBP, and confirmed that chronic wounds would require EBP.
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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 Brentwood
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Nhc Place At Cool Springs | 5.1 mi | ★★★★★ | 0 | 0 |
| Bethany Center For Rehabilitation And Healing Llc | 5.2 mi | ★★★★★ | 0 | 0 |
| Woodcrest At Blakeford | 6.5 mi | ★★★★★ | 10 | 0 |
| Green Hills Center For Rehabilitation And Healing | 7.2 mi | ★★★★★ | 5 | 0 |
| Mulberry Health & Rehabilitation | 7.8 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 October 2026) and official state health department websites.