Brookwood Gardens Rehabilitation and Nursing Cente

In the surveyor’s words

From the most serious findings on record at Brookwood Gardens Rehabilitation and Nursing Cente, in the surveyor’s own words.

• Actual harm, isolatedF689Jun 10, 2026

  Based on observation, interview, and record review, it was determined that the facility failed to ensure procedures and safety measures were in place for the temperature and serving of hot beverages for one (Resident #1) of three residents reviewed. Staff served hot coffee without checking the temperature to Resident #1, an individual with upper extremity weakness who was left unsupervised. Subsequently, the coffee was spilled, resulting in Resident #1 sustaining third-degree (full thickness) burns on the abdomen, left hip, and right lower back. This incident led to a notable level of harm. […]

• Actual harm, isolatedF600Apr 10, 2024

  Based on record review and interviews, the facility failed to ensure one (Resident #2) out of three sampled residents was free from abuse and neglect and is determined to be at a level of harm, as evidenced by: the facility's staff failure to implement interventions for constipation and prevention of fecal impaction that resulted in the fecal impaction of Resident # 2 who subsequently expired after being transferred to the hospital. There were 155 residents residing in the facility at the time of the survey. The findings included: Review of Resident #2's medical records revealed the resident was initially admitted to the facility on [DATE] and readmitted on [DATE]; and discharged to the hospital on [DATE]. […]

• Actual harm, isolatedF684Apr 10, 2024

  Based on record review and interviews, the facility failed to ensure one (Resident #2) out of three sampled residents received care and treatment in accordance with professional standards of practice related to consistency in the resident's bowel management; that include but not limited to interventions for constipation and prevention of fecal impaction. Resident # 2 expired in the hospital and was diagnosed with fecal impaction. This deficient practice was determined to be at the level of harm. […]

• No harm, potential for more than minimal, widespreadF812Aug 28, 2025

  Based on observations, interviews and record review the facility failed to store food under sanitary condition by ensuring the proper temperatures in the 1) walk-in refrigerator and walk-in freezer and ensure the walk-in refrigerator and walk-in freezer were working properly and 2) ensure that staff wore hair nets when in the kitchen. The food items in the walk-in refrigerator had condensation on them, the food items in the walk-in freezer were soft to the touch and the ice creams were melted. […]

• No harm, potential for more than minimal, widespreadF908Aug 28, 2025

  Based on observations, interviews and record review the facility failed to ensure the walk-in refrigerator and walk-in freezer were working properly. This has the potential to affect 156 out of 167 residents who eat orally residing in the facility at the time of the survey.The findings included:Record review of the Food Storage Policy and Procedure (no written dated documented); Policy-Sufficient storage facilities are provided to keep foods safe, wholesome and appetizing. Food is stored, prepared and transported at an appropriate temperature and by methods designed to prevent contamination; Procedures-16) Refrigerator temperatures: a) Temperature for refrigerators should be 41 degrees F (Fahrenheit), b) Every refrigerator must be equipped with an internal thermometer and 17) Freezer… […]