Brooke Grove Rehab. & NSG CTR

In the surveyor’s words

From the most serious findings on record at Brooke Grove Rehab. & NSG CTR, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF609Apr 1, 2025

  Based on administrative and medical record review and interviews with facility staff it was determined the facility staff failed to report allegations of resident abuse in a timely manner. This was found to be evident for 8 (Resident #193, #169, #191, #24, #170, # 172, #188, #194) of 8 residents reviewed for abuse during the facility's survey. Findings include, 1. Intake MD00212529 was reviewed on 3/31/25 at 10:43 AM for allegations of abuse. Review of the facility's investigation revealed that a PRN (as needed) Physical Therapist (PT) (#17) observed Resident #193 and Nurse (#18), forcefully administer medication to the resident, and continued, even after the resident began choking. […]

• No harm, potential for more than minimal, patternF610Apr 1, 2025

  Based on record review and interviews it was determined that the facility staff failed to complete a thorough investigation of allegations of abuse. This deficient practice was evidenced in 4 (#170, #172, #188, #194) of 4 facility reported incident investigations reviewed during the recertification survey. The findings include: 1. On 03/27/25 at 9:14 am a review of the self-report related to Resident #188 revealed the resident reported being abused by a nurse. The alleged perpetrator's statement indicated they did not work with the resident on the day of the alleged incident, nor did the statement deny or confess that the alleged incident happened. The staff who worked with the resident the day the alleged incident was reported was not interviewed. […]

• No harm, potential for more than minimal, patternF812Apr 1, 2025

  Based on observations and staff interviews, it was determined that the facility staff failed to ensure food items in the kitchen and unit refrigerator were stored to maintain the integrity of the specific items and failed to ensure equipment temperature logs were maintained for monitoring. This was evidence in observations in the kitchen and west wing refrigerators. The findings include: 1a) On 03/26/25 at 07:41 AM, an initial observation of the facility kitchen vegetable fridge revealed a bag of spinach opened and unlabeled, a bag of iceberg lettuce opened and unlabeled, a carrot bag opened and unlabeled, tahini opened and unlabeled, honey mustard salad dressing opened and unlabeled, a vanilla butter cream container that was opened and unlabeled, pre-poured french dressing into single… […]

• No harm, potential for more than minimal, isolatedF550May 22, 2026

  Based on observations and interviews, it was determined that the facility failed to ensure the dignity of the residents during meal times. This was evident for 1 (#148) of 3 residents reviewed for dignity during this annual survey.The findings include:On 5/21/2026 at 10:11 AM, the surveyor visited Resident #148 and noted that the resident had not eaten breakfast yet. The surveyor asked Resident #148 if they had had their breakfast. Resident #148 responded that they had not had breakfast and that they were hungry. The surveyor then asked the roommate if they had breakfast already. The roommate answered yes and said that it was around 9 AM when they received their tray. The surveyor then asked the roommate if anyone had come in to feed Resident #148. […]

• No harm, potential for more than minimal, isolatedF554May 22, 2026

  Based on observation, record review, and interviews, it was determined that the facility failed to assess a resident's ability to self-administer medication, and to develop and implement a person-centered care plan for safe self-administration. This was found to be evident for 1 (#144) of 32 residents observed during initial screening on the 1st floor rehab units.The findings include:On 5/18/2026 at 10:44AM, during an initial tour of the 1st floor rehab unit, the Surveyor observed Resident #144 in possession of a white paper medicine cup containing multiple pills. The resident stated I like to take my pills slowly, one at a time. The nurse will come back to check on me. […]