Brookwood Care Center

In the surveyor’s words

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

• No harm, potential for more than minimal, widespreadF812Jan 23, 2026

  Based on observation, interview, facility policy review, and Food and Drug Administration (FDA) Food Code recommendations, the facility failed to ensure staff wore effective hair restraints while in the facility's kitchen. This failure had the potential to affect 104 residents who received meals from the kitchen. The facility census was 111. Findings included:The 2022 FDA Food Code, Chapter 2-402.11, indicated, (A) Except as provided in (B) of this section, FOOD EMPLOYEES shall wear hair restraints such as hats, hair coverings or nets, beard restraints, and clothing that covers body hair, that are designed and worn to effectively keep their hair from contacting exposed FOOD; clean EQUIPMENT, UTENSILS, and LINENS; and unwrapped SINGLE-SERVICE and SINGLE-USE ARTICLES.A facility policy… […]

• No harm, potential for more than minimal, patternF804Jul 9, 2026

  Based on review of test tray, staff interview, and policy review, the facility failed to ensure food was palatable and served at an appropriate temperature. This affected three (#21, #97, and #112) residents and had the potential to affect 99 residents in the facility. The facility identified nine residents (#80, #83, #84, #85, #87, #92, #94, #96, and #108) who did not receive food from the kitchen.Findings include: Observation on 07/09/26 at 8:41 A.M. of a test tray revealed the scrambled eggs were 104 degrees Fahrenheit (F), potatoes were 100 degrees F, and the milk was 56 degrees F. The eggs and potatoes were not hot to taste and not palatable. […]

• No harm, potential for more than minimal, patternF921Jul 9, 2026

  Based on observation, staff interview, and policy review, the facility failed to maintain fans and vents in a clean and sanitary manner. This had the potential to affect all 43 residents on the second floor of the facility. The facility census was 108. Findings include: Observation on 07/08/26 at 10:06 A.M. revealed a large industrial fan at the beginning of the Recovery Road hall. The back of the fan was blowing air down the hall and was heavily coated in a fuzzy grey material. Continued observation revealed an additional tower fan in the center of the hall, blowing air in all directions. The intake vent was heavily coated in a fuzzy grey material and blowing in the breeze from the fan. Further observation revealed there were multiple residents on ventilators on the Recovery Road hall. […]

• No harm, potential for more than minimal, patternF584Jan 23, 2026

  Based on interview, facility document review, and policy review, the facility failed to maintain a comfortable environment when temperatures exceeded 81 degrees Fahrenheit (F) for six days, which affected 1 of 2 facility floors with 60 resident rooms. The facility census was 111. Findings included:A facility policy titled, Quality of Life - Homelike Environment, revised May 2017, revealed, Residents are provided with a safe, clean, comfortable and homelike environment. The policy also indicated, 2. The facility staff and management shall maximize, to the extent possible, the characteristics of the facility that reflect a personalized, home like setting. These characteristics include, and h. […]

• No harm, potential for more than minimal, patternF805Jan 23, 2026

  Based on facility policy review, facility document review, observation, and interview, the facility failed to ensure residents received food in a form designed to meet individual needs during the lunch meal on 01/20/2026, which had the potential to affect the 11 residents at the facility who had a physician ordered mechanical soft diet. The facility census was 111. Findings included:An undated facility policy titled, Accuracy of Quality of Tray Line Service, indicated, All meals will be checked for accuracy by the food and nutrition services staff, and by the service staff prior to serving the meal to the individual. The policy further indicated the Procedure included, 1. […]