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BRENTWOOD REHABILITATION AND HEALTHCARE CTR (THE) Inspection Report, Violations & Safety Grade (DANVERS, Massachusetts)

56 LIBERTY STREET, DANVERS, Massachusetts 01923

Phone: 9787772700

CMS Overall:5/5

Overview & Bed Count

Certified Beds
159
Avg Residents/Day
133.5
Ownership
For profit - Limited Liability company
Provider Type
Medicare and Medicaid
County
Essex
Sprinkler Systems
Yes
Special Focus
None
Abuse Icon
No

CMS Star Ratings

Overall5/5
Health4/5
Staffing2/5
Quality5/5

Nurse Staffing Check

MetricThis FacilityMassachusetts AvgDifference
RN Hours per Resident per Day0.550.66-0.10
Total Nurse Hours per Resident per Day3.613.94-0.33
CMS Staffing Rating2/53.1/5-
Nursing Staff Turnover31.1%37.6%-

Health Citation History

20 health citations on record

DateCategoryDescriptionSeverity
2025-03-13Pharmacy Service DeficienciesEnsure medication error rates are not 5 percent or greater.E – Moderate Harm Potential
2025-03-13Resident Assessment and Care Planning DeficienciesSafeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.E – Moderate Harm Potential
2025-03-13Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.D – Moderate Harm Potential
2025-03-13Resident Rights DeficienciesHonor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances.D – Moderate Harm Potential
2025-03-13Resident Assessment and Care Planning DeficienciesEnsure services provided by the nursing facility meet professional standards of quality.D – Moderate Harm Potential
2025-03-13Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2025-03-13Quality of Life and Care DeficienciesProvide appropriate pressure ulcer care and prevent new ulcers from developing.D – Moderate Harm Potential
2025-03-13Quality of Life and Care DeficienciesProvide enough food/fluids to maintain a resident's health.D – Moderate Harm Potential
2025-03-13Quality of Life and Care DeficienciesProvide for the safe, appropriate administration of IV fluids for a resident when needed.D – Moderate Harm Potential
2025-03-13Pharmacy Service DeficienciesEnsure that residents are free from significant medication errors.D – Moderate Harm Potential
2025-03-13Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.D – Moderate Harm Potential
2025-03-13Infection Control DeficienciesProvide and implement an infection prevention and control program.D – Moderate Harm Potential
2024-03-28Resident Rights DeficienciesHonor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.E – Moderate Harm Potential
2024-03-28Nursing and Physician Services DeficienciesProvide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift.E – Moderate Harm Potential
2024-03-28Nutrition and Dietary DeficienciesEnsure food and drink is palatable, attractive, and at a safe and appetizing temperature.E – Moderate Harm Potential
2024-03-28Nutrition and Dietary DeficienciesProcure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.E – Moderate Harm Potential
2024-03-28Resident Assessment and Care Planning DeficienciesDevelop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.D – Moderate Harm Potential
2024-03-28Quality of Life and Care DeficienciesProvide appropriate treatment and care according to orders, resident’s preferences and goals.D – Moderate Harm Potential
2024-03-28Pharmacy Service DeficienciesEnsure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.D – Moderate Harm Potential
2024-03-28Resident Assessment and Care Planning DeficienciesEnsure each resident receives an accurate assessment.B – Minimal Harm Potential

Fire Safety Citation History

7 fire safety citations on record

DateCategoryDescriptionSeverity
2026-04-22Gas, Vacuum, and Electrical Systems DeficienciesMeet requirements for the installation and maintenance of electrical systems.F – Moderate Harm Potential
2026-04-22Smoke DeficienciesHave an enclosure around a vertical opening shaft.E – Moderate Harm Potential
2026-04-22Miscellaneous DeficienciesProvide a written emergency evacuation plan.E – Moderate Harm Potential
2026-04-22Smoke DeficienciesInstall a fire alarm system that can be heard throughout the facility.D – Moderate Harm Potential
2026-04-22Services DeficienciesHave properly installed electrical wiring and gas equipment.D – Moderate Harm Potential
2026-04-22Smoke DeficienciesInspect, test, and maintain automatic sprinkler systems.C – Minimal Harm Potential
2025-03-13Egress DeficienciesAdd doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.F – Moderate Harm Potential

Total Penalties & Fines

$0
Total Fine Amount (CMS)
0
Number of Fines
0
Total Penalties

No penalty records found.

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