MGHP-BRENTWOOD LLC Nursing Home


MGHP-BRENTWOOD LLC (CCN: 115361) is a For profit - Corporation facility located in WAYNESBORO, GA (30830). The facility has an overall rating of 5/5, health inspection rating of 5/5, and a staffing rating of 3/5. It offers 103 certified beds and maintains an average of 41.8 residents per day. The nursing staff includes Nurse Aides, LPNs, and RNs working 3.98966 total hours per resident per day. It has been certified since April 1, 1989 and the last listed health inspection was on August 24, 2023, The facility is located in Burke county and provides senior and nursing home care.

MGHP-BRENTWOOD LLC Summary


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Provider Name: MGHP-BRENTWOOD LLC

Address: 115 BRENTWOOD DRIVE, WAYNESBORO, GA 30830

Phone: (706) 554-4425

County: Burke (150)

Ownership Type: For profit - Corporation

Certified Beds: 103

Average Residents Per Day: 41.8 ()

Provider Type: Medicare and Medicaid, Resides in Hospital: No

Legal Business Name: MGHP-BRENTWOOD LLC

First Approved Date: April 1, 1989

Affiliated Entity: ()

Retirement Community: N, Special Focus Status:

Ownership Change in Last 12 Months: Y

Resident Family Council: Resident

Sprinkler System Status: Yes

Overall Rating: 5 ()

Health Inspection Rating: 5 ()

QM Rating: 3 ()

Long Stay QM Rating: 3 ()

Short Stay QM Rating: (2)

Staffing Rating: 3 ()

Staffing Report Note:

PT Staffing Note:

Nurse Aide Staff Hours Per Day, per resident: 2.14891, LPN Staff Hours Per Day: 1.2566, RN Staff Hours Per Day: 0.5840, Licensed Staff Hours Per Day: 1.8407

Total Nurse Staff Hours Per Day, per resident: 3.98966

Weekend Nurse Staff Hours: 3.37742, Weekend RN Staff Hours: 0.3885

PT Staff Hours Per Day, per resident: 0.0133

Nurse Staff Turnover: 47.4, Nurse Turnover Note:

RN Turnover: 71.4, RN Turnover Note:

Admin Left Number: 1, Admin Turnover Note:

Case Mix Nurse Aide Hours Per Day, per resident: 2.0461, Case Mix LPN Hours Per Day: 0.6951, Case Mix RN Hours Per Day: 0.3285

Adjusted Nurse Aide Hours Per Day, per resident: 2.13954, Adjusted LPN Hours Per Day: 1.3340, Adjusted RN Hours Per Day: 0.6699

Total Adjusted Nurse Hours Per Day, per resident: 4.09644

Adjusted Weekend Nurse Hours Per Day, per resident: 3.46781

Health Survey Dates and Scores: Cycle 1: 2023-08-24 (Score: 8), Cycle 2: 2021-11-04 (Score: 0), Cycle 3: 2019-12-12 (Score: 0)

Total Weighted Health Score: 4.000

Reported Incidents: 0, Substantiated Complaints: 0

Infection Control Citations:

Fines and Penalties: Number of Fines: 1, Total Fines in Dollars: 3145.35, Payment Denials Number: 0, Total Penalties Number: 1

Location and GPS: 115 BRENTWOOD DRIVE,WAYNESBORO,GA,30830 (33.0833, -82.011)

Process Date: 2024-03-01


Health Inspection Citations Details

Each record details specific health deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-08-24

Type: Health, Deficiency: Encode each resident’s assessment data and transmit these data to the State within 7 days of assessment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-24

Type: Health, Deficiency: Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06


Fire Safety Citations Details

Each record details specific fire safety deficiencies found during inspections, categorized by type, severity, and whether they were corrected. Below are the severity levels and their implications:

Citation on 2023-08-22

Type: Fire Safety, Tag: 0026, Version: New

Description: Establish roles under a Waiver declared by secretary.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0030, Version: New

Description: List the names and contact information of those in the facility.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0037, Version: New

Description: Establish staff and initial training requirements.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0222, Version: New

Description: Add 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.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0223, Version: New

Description: Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0311, Version: New

Description: Have an enclosure around a vertical opening shaft.

Severity: E - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0321, Version: New

Description: Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0341, Version: New

Description: Install a fire alarm system that can be heard throughout the facility.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0355, Version: New

Description: Properly select, install, inspect, or maintain portable fire extinguishes.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0372, Version: New

Description: Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2023-08-22

Type: Fire Safety, Tag: 0511, Version: New

Description: Have properly installed electrical wiring and gas equipment.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2023-10-06

Citation on 2019-12-10

Type: Fire Safety, Tag: 0291, Version: New

Description: Install emergency lighting that can last at least 1 1/2 hours.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2020-01-24

Citation on 2019-12-10

Type: Fire Safety, Tag: 0353, Version: New

Description: Inspect, test, and maintain automatic sprinkler systems.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2020-01-24

Citation on 2019-12-10

Type: Fire Safety, Tag: 0374, Version: New

Description: Install smoke barrier doors that can resist smoke for at least 20 minutes.

Severity: D - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2020-01-24

Citation on 2019-12-10

Type: Fire Safety, Tag: 0511, Version: New

Description: Have properly installed electrical wiring and gas equipment.

Severity: F - Level 2: No actual harm with potential for more than minimal harm. Plan of Correction required.

Corrected: Deficient, Provider has date of correction on 2020-01-24