Brookview Health Care Center

In the surveyor’s words

From the most serious findings on record at Brookview Health Care Center, in the surveyor’s own words.

• Immediate jeopardy, patternF607Feb 16, 2024

  Based on review of policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that staff reported physical abuse in a timely manner, which allowed the staff member to return to the resident to be mentally abused for one of five residents reviewed (Resident 2) putting all of the residents in danger of being abused, resulting in Immediate Jeopardy to their physical and mental safety. This deficiency was cited as past non-compliance. […]

• Immediate jeopardy, isolatedF600Feb 16, 2024

  Based on review of facility policies, clinical records, and investigation documents, as well as staff interviews, it was determined that the facility failed to ensure that residents were free from physical and mental abuse for one of five residents reviewed (Resident 2), resulting in Immediate Jeopardy to the resident's physical, mental health, and safety. This deficiency was cited as past non-compliance. Findings include: The facility's abuse policy, dated April 13, 2023, revealed that it is the policy of the facility to provide protections for the health, welfare, and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation, and misappropriation of resident property. […]

• Immediate jeopardy, isolatedF743Feb 16, 2024

  Based on review of policies, clinical records, and personnel files, as well as staff interviews, it was determined that the facility failed to properly address a resident's behavior of repeatedly taking her feet off the wheelchair footrests and placing them on the ground for one of five residents reviewed (Resident 2), resulting in Immediate Jeopardy when the nurse aide continued to grab hold of the resident's ankles, causing her to yell out and place her feet back on the ground, which resulted in the resident hitting the nurse aide while the nurse aide was bent over to once again grab the resident's ankles to place the her feet back on the wheelchair footrests. In response, the nurse aide slapped the resident's hand and called the resident an asshole. […]

• No harm, potential for more than minimal, patternF684Feb 26, 2025

  Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for three of 24 residents reviewed (Residents 17, 32, 56). Findings include: The facility's policy regarding medication administration, dated April 11, 2024, revealed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. […]

• No harm, potential for more than minimal, patternF812Feb 26, 2025

  Based on observations and staff interviews, it was determined that the facility failed to ensure that ice was made and stored in sanitary ice machines for one of two ice machines ([NAME] House). Findings include: Observations of the ice machine in the [NAME] House pantry on February 24, 2025, at 8:16 a.m. and February 25, 2025, at 9:16 a.m. revealed that the drain pipe coming from the ice machine extended down to the floor and ran horizontally to the floor drain, resulting in no air gap between the end of the ice machine's drain pipe and the floor drain. Interview with Maintenance Worker 1 on February 25, 2025, at 9:27 a.m. confirmed that the ice machine in the [NAME] House Kitchen did not have an air gap between the drain pipe and the floor drain for back-flow prevention. 28 Pa. […]