The Villas at Brookview

In the surveyor’s words

From the most serious findings on record at The Villas at Brookview, in the surveyor’s own words.

• Immediate jeopardy, isolatedF760Dec 11, 2025

  Based on interview and document review, the facility failed to ensure 1 of 3 residents (R3) was free from a significant medication error. This resulted in an Immediate Jeopardy (IJ) for R3 who was given the wrong dose of medication that resulted in hospitalization in the intensive care unit. The IJ began on 11/4/25 at 7:07 a.m. when R3 was administered the incorrect amount of 40 milligrams (mg) of methadone (a long-acting opioid pain medication) which was 16 times the prescribed amount of 2.5 mg. The administrator and director of nursing (DON) were notified of the IJ on 11/7/2025 at 1:50 p.m. […]

• No harm, potential for more than minimal, widespreadF812Apr 16, 2026

  Based on observation, interview, and document review, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwasher observed. This had the potential to affect all current residents, as well as staff or visitors, who ate food served from dishes and tableware that were cleaned in the dishwasher.Additionally, the facility failed to ensure food items were properly labeled, dated, and stored in the walk-in freezer. The facility also failed to assure that proper hair and beard restraints were used by staff members preparing food within the kitchen. […]

• No harm, potential for more than minimal, patternF761Mar 17, 2026

  Based on observations, interviews, and document review, the facility failed to ensure medications were stored securely in areas where residents, staff and guests could not access medications in 1 of 1 medication carts observed, potentially affecting one unit, Unit 400, of the facility. Findings include: During observation and interviews on 3/13/26 at 12:27 p.m., Employee (E)-I walked away from the medication cart, leaving it unlocked in the hallway of the 400 unit, stationed between resident rooms. At 12:31 p.m., the Director of Social Services (DSS)-A walked by the cart and pulled on the locked narcotics drawer. The DSS-A stated she was making sure the drawer was locked and then walked away. The cart remained unlocked and unattended until 12:37 p.m., when E-I returned to the cart. […]

• No harm, potential for more than minimal, patternF770Sep 17, 2024

  Based on interview and document review the agency failed to maintain current certification for the Clinical Laboratory Improvement Amendments (CLIA) waiver, which is required for agencies performing blood testing. This had the potential to affect patients who received blood testing by the agency, including those residents who had received routine glucose testing (check of blood sugar). This included R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, and R35. On [DATE], at 10:00 a.m. a review of the facility certifications was completed upon entrance to the facility. At this time, a document dated [DATE], indicated the CLIA waiver became effective [DATE] and expired on [DATE]. On [DATE], at 2:00 p.m. […]

• No harm, potential for more than minimal, isolatedF677Aug 27, 2026

  Based on observation, interview, and document review the facility failed to offer necessary assistance to a dependent resident with meal assistance for 1 of 3 residents (R4) reviewed for activities of daily living (ADL) assistance.Findings include:During an observation in the 4th floor dining room on 8/27/26, from 8:15 a.m. to 8:40 a.m., R4 sat in his wheelchair with his untouched tray in front of him. The tray consisted of a bowl of oatmeal, two pieces of bacon, a piece of toast, and scrambled eggs. Silverware was present. R4 was observed to drink some of his water but made no attempt to eat. […]