Average — CMS composite of the measures below.
A standard survey is most likely before around November 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookwood Gardens Rehabilitation And Nursing Cente during CMS and state inspections, most recent first.
The facility did not ensure that food was procured from approved sources or that food was stored, prepared, distributed, and served according to professional standards.
Surveyors found that the walk-in refrigerator and freezer were not maintaining safe temperatures, with the refrigerator reaching 55°F and the freezer at 40°F. Food items, including meats, eggs, and ice cream, were improperly stored and not kept at required temperatures, and condensation was observed. Maintenance staff were aware of the issue, but the equipment had not been repaired, and temperature logs did not reflect the actual unsafe conditions.
The facility was cited for repeated failures to effectively implement and sustain QAPI and QAA activities, resulting in ongoing deficiencies related to food procurement, storage, preparation, sanitary practices, and resident dignity during dining. Despite regular QAPI committee meetings and established policies, the same issues were identified in multiple surveys.
Surveyors identified repeated deficiencies related to resident dignity during dining, food procurement and sanitary practices, and essential equipment safety. Despite the presence of a QAPI committee with regular meetings and a policy in place, the facility did not demonstrate that effective corrective actions were implemented to resolve these ongoing issues.
Fifteen residents experienced delayed lunch tray delivery when CNAs waited for nurses to check and hand over trays, resulting in a 15-minute wait after the food cart arrived. Staff interviews confirmed that only nurses could remove trays from the cart, causing the delay and affecting residents' dining experience.
The facility did not properly organize or support Resident Council meetings, resulting in unresolved issues such as missing clothing, delayed call light responses, inadequate snacks, and dissatisfaction with food quality. Residents reported ongoing grievances, and staff interviews revealed that food preferences and alternative meal options were not consistently addressed or communicated. Documentation of follow-up and resolution for concerns raised in meetings was lacking.
Confidential resident health insurance information was left unattended and visible on a medication cart at one nursing station. A RN acknowledged the lapse, stating the information should have been covered according to facility protocol, but was not due to being occupied with resident care. The DON confirmed the expectation for all resident information to remain covered.
Facility failed to complete accurate Level I PASRR screens for two residents with documented psychotic disorders. Both residents had MDS coding, care plans, psychotropic meds, and psych notes reflecting psychosis, but the PASRR MI/suspected MI section did not check psychosis. Interviews with the MDS RN, Social Services Director, and DON confirmed the residents had psychotic disorder documented and should have been included on the PASRR.
The facility did not maintain an effective pest control program, as evidenced by multiple sightings of roaches in resident areas and reports of bugs in rooms. Pest control services were reportedly provided weekly, but pests, including roaches and lizards, were still observed inside and outside the building.
The facility failed to ensure proper food safety and sanitation practices, including undated food items in the refrigerator, lack of a thermometer in the milk box, and a rust-laden dish machine hood ventilation system. These issues have the potential to affect the majority of residents who consume food orally.
The facility failed to provide advance directives documentation for seven residents. Record reviews and interviews revealed that while advance directives are part of the admission package, there is no documentation confirming that residents or their representatives were offered and declined to execute these directives. The facility's policy requires that any existing advance directives be included in the medical record, but this was not followed for the sampled residents.
The facility failed to implement an effective QAPI program, resulting in repeated deficiencies related to the labeling and storage of drugs and biologicals, sanitary food handling, and infection control. Despite having a QAA committee and PIPs in place, the facility did not address these issues effectively, putting 142 residents at potential risk.
A CNA improperly disposed of a biohazard bag in a bin with a white lid instead of the designated biohazard box, leading to a deficiency in infection control practices. The CNA later corrected the mistake, and the Director of Nursing confirmed the proper disposal procedures as per the facility's policy.
The facility failed to ensure the high temperature dish machine reached the required temperatures for the wash and final rinse cycles, affecting the sanitation of dishware for residents. Observations and interviews confirmed the issue, which was caused by a knife stuck in the dish machine drain.
A CNA was observed standing while assisting a resident with breakfast, contrary to the facility's protocol requiring staff to be seated to maintain resident dignity. The DON confirmed the requirement, and the facility's policy emphasizes treating residents with respect and dignity during daily activities.
The facility failed to accurately code the MDS for a resident who was discharged home, incorrectly indicating that the resident was discharged to a hospital. The error was identified through record reviews and acknowledged by the MDS Coordinator as an oversight.
The facility failed to maintain accurate drug records for a resident's Clonazepam 0.5 mg tablets. A narcotic count revealed a discrepancy between the blister pack and the Controlled Drug Receipt/Proof of use/Disposition form. The nurse admitted to forgetting to sign the form after administering the medication due to being distracted. The facility's policy mandates special handling and record-keeping for controlled drugs, which was not followed in this instance.
A facility failed to properly store medications for a resident, as two tablets were found in the resident's room without staff present. The resident, who has Systemic Lupus Erythematosus, was not approved to self-medicate. Facility protocol was followed after the discovery.
A facility failed to ensure a resident with multiple contractures wore prescribed splints to prevent worsening of their condition. Despite a physician's order and multiple observations, the resident was not consistently wearing the required splints, and the care plan lacked necessary interventions.
A resident with multiple health conditions, including dementia, experienced severe constipation and fecal impaction due to the facility's failure to monitor and document bowel movements. Despite care plans and physician orders, staff did not implement necessary interventions, leading to the resident's hospitalization and subsequent death from septic shock and other complications.
A resident with multiple health conditions was found to have a fecal impaction upon hospital admission, leading to septic shock and death. The facility failed to consistently monitor and document the resident's bowel movements, despite having a bowel management protocol in place. The resident's condition deteriorated after a fall, highlighting significant lapses in care and communication among staff.
Non-Compliance with Food Procurement and Handling Standards
Penalty
Summary
The facility failed to procure food from approved or satisfactory sources and did not store, prepare, distribute, or serve food in accordance with professional standards. This deficiency was identified during the survey process, indicating non-compliance with established food safety and handling requirements. No additional details regarding specific residents, staff, or events leading to the deficiency are provided in the report.
Failure to Maintain Safe Temperatures in Walk-In Refrigerator and Freezer
Penalty
Summary
The facility failed to ensure that the walk-in refrigerator and walk-in freezer were functioning properly, as observed during a kitchen tour. The walk-in refrigerator was found to have an exterior temperature of 50°F and an interior temperature of 55°F, with condensation noted on stored items such as produce, pasteurized eggs, juices, and thawed meats. The walk-in freezer was observed with an exterior temperature of 38°F and an interior temperature of 40°F, and foods inside, including breakfast foods, vegetables, meats, and ice cream, were not frozen and were soft to the touch. Photographic evidence was submitted to document these findings. Interviews revealed that maintenance staff had been aware for some time that the temperatures in both units were not within acceptable ranges, but repairs had not been completed. Review of temperature logs for the walk-in refrigerator and freezer showed recorded temperatures within acceptable ranges, which did not match the actual observed temperatures during the survey. The facility's Food Storage Policy required refrigerators to be maintained at 41°F or below and freezers at 0°F or below, with daily temperature recordings and internal thermometers, but these requirements were not met at the time of the survey.
Repeated Deficiencies in QAPI and QAA Implementation
Penalty
Summary
The facility failed to ensure effective implementation and sustainability of its Quality Assurance and Performance Improvement (QAPI) and Quality Assessment and Assurance (QAA) activities, as evidenced by repeated deficiencies identified during multiple recertification surveys. Specifically, the facility was cited for ongoing issues related to food procurement, storage, preparation, and sanitary practices, as well as resident rights concerning dignity during dining. These deficiencies were noted in both the previous and current recertification surveys, indicating a pattern of non-compliance and insufficient corrective action over time. During a QAPI review, it was confirmed that the QAPI committee, which includes the NHA, DON, Assistant DON, Medical Director, Pharmacy Representative, and all department heads, had met recently and reviewed activities and goals related to previously cited deficiencies. Despite having a documented policy outlining the purpose and scope of the QAA committee and QAPI program, the facility continued to exhibit repeated deficient practices in the same areas, demonstrating a lack of effective and sustained improvement.
Repeated Deficiencies in Dignity, Food Safety, and Equipment Despite QAPI Oversight
Penalty
Summary
The facility failed to demonstrate that effective plans of action were implemented to correct previously identified quality deficiencies. Repeated deficiencies were cited in the areas of resident dignity during dining (F550), food procurement, storage, preparation, and sanitary practices (F812), and essential equipment in safe operating condition (F908). These deficiencies were observed during both the previous and current recertification surveys, indicating that the same issues persisted over time. The survey history shows that the facility was cited for F550 and F812 in both surveys, and F908 was added in the most recent survey. During a review of the Quality Assurance and Performance Improvement (QAPI) committee activities, it was found that the committee, which includes the NHA, DON, Assistant DON, Medical Director, Pharmacy Representative, and all department heads, had last met on 08/15/2025. Despite the existence of a QAPI committee and a policy outlining its purpose and scope, the facility did not provide evidence that effective corrective actions were implemented to address the recurring deficiencies. The report is based on observations, interviews, and record reviews conducted by surveyors.
Delayed Meal Tray Delivery Compromises Dignified Dining Experience
Penalty
Summary
The facility failed to ensure a dignified dining experience for residents who dined in their rooms, as lunch trays for 15 out of 22 residents on the 300 South Cart 1 were not delivered in a timely manner. Observations showed that after the food cart arrived, Certified Nursing Assistants (CNAs) waited by the cart and did not deliver trays to residents until nurses handed the trays to them. The lunch cart sat for approximately 15 minutes before the trays were distributed, resulting in a delay in meal service for the affected residents. Interviews with staff revealed that CNAs were not permitted to deliver trays until a nurse checked the consistency of the food with the meal ticket and physically handed the tray to the CNA. The Director of Nursing and a Registered Nurse confirmed this process, stating that only nurses could remove trays from the cart and that trays should be passed within five minutes of arrival. However, the observed practice led to a significant delay, impacting the residents' right to a dignified and timely dining experience.
Failure to Organize and Address Resident Council Concerns
Penalty
Summary
The facility failed to ensure that resident group meetings, specifically the Resident Council, were organized and structured in a manner that supported residents' rights to participate and have their concerns addressed. Observations of a Resident Council meeting showed low attendance, with only one consistent council member and several first-time attendees. Review of meeting minutes from January through May revealed ongoing, unresolved issues such as missing clothing, delayed call light responses, inadequate snack availability, and dissatisfaction with food quality. There was no meeting held in June, and no documentation was found regarding follow-up or resolution of previously raised concerns. Interviews with residents indicated continued dissatisfaction with food quality, small portion sizes, and repetitive meals, as well as ongoing issues with missing clothing and unresolved grievances. The Food Service Director stated that menus are developed corporately and only slightly adjusted based on resident input, with no always available menu. Alternative meal options are dependent on leftovers or available items, and residents dining in-room must request alternatives to be informed of them. CNAs are expected to offer alternatives and report unmet needs, but there was no verification of this process. Portion increases are only made after reported weight loss or formal requests to the dietitian. The facility's policy requires prompt action on grievances and documentation of responses, but these steps were not demonstrated.
Unattended Resident Health Information Left Visible at Nursing Station
Penalty
Summary
A deficiency occurred when confidential resident information, specifically a census containing health insurance details, was left unattended and visible on top of a medication cart at the East Nursing Station. This was observed by a surveyor, who noted that the information was accessible and not secured while staff were away from the cart. Upon return, a registered nurse acknowledged that the facility's protocol requires resident information to be covered at all times, but admitted to not following this protocol due to assisting a resident and forgetting to secure the documents. The Director of Nursing confirmed that the expectation is for all resident information to remain covered. Facility policy also states that resident health information must be kept private and confidential.
PASRR Screens Omitted Psychosis for Two Residents
Penalty
Summary
Facility failed to ensure accurate Level I PASRR screenings were completed for two residents with documented psychotic disorders. Resident #6 was admitted and readmitted with diagnoses including unspecified psychosis not due to a substance or known physiological condition, and the record also showed depression, psychotic disorder other than schizophrenia, unspecified mood disorder, and primary insomnia. The resident’s care plan addressed psychosis, and later records included an order for risperidone related to unspecified psychosis and a psychiatry progress note listing unspecified psychosis. However, the Level I PASRR completed on 4/9/25 did not check psychosis in the section for MI or suspected MI. Resident #4 was admitted and readmitted with diagnoses including unspecified psychosis not due to a substance or known physiological condition, major depressive disorder, primary insomnia, unspecified mood disorder, and anxiety disorder. The resident’s MDS referenced psychotic disorder other than schizophrenia, the care plan addressed psychosis, and later records included an order for quetiapine for unspecified psychosis and a psychiatry progress note listing unspecified psychosis. Despite this documentation, the Level I PASRR completed on 5/22/25 did not check psychosis in the MI or suspected MI section. During interviews, the MDS RN stated both residents were coded on the MDS for psychotic disorder, the Social Services Director described the PASRR review process, and the DON stated psychotic disorder was listed on the last psychiatric eval and should have been included on the PASRR.
Failure to Maintain Effective Pest Control Program
Penalty
Summary
The facility failed to maintain an effective pest control program, resulting in the presence of roaches within the building. During observations, a roach was seen crawling on the wall behind a resident who was in bed, and another roach was observed outside a resident's room in the 300 South Wing. Additionally, while interviewing a resident's wife, a roach was seen crawling up the wall in the same wing. The resident's wife also reported the presence of bugs in the room. The Administrator confirmed that pest control services are provided weekly and acknowledged recent sightings of pests, including lizards and baby lizards, both inside and outside the facility. The facility's pest control policy requires ongoing efforts to keep the building free of insects and rodents, with services provided by an external company and assistance from maintenance staff as needed.
Food Safety and Sanitation Deficiencies
Penalty
Summary
The facility failed to ensure proper food safety and sanitation practices in the kitchen, affecting the majority of its residents. During an initial kitchen tour, surveyors observed opened and undated mozzarella cheese and egg salad in the walk-in refrigerator. The Accounts Manager/Food Service Director confirmed that these items should have been dated when opened and discarded if not properly labeled. Additionally, the milk box was found to lack a thermometer, which is necessary to ensure that cold foods are maintained at temperatures of 41 degrees Fahrenheit or below. The Accounts Manager/Food Service Director acknowledged the absence of the thermometer and stated that one would be placed in the milk box immediately. Further observations revealed that the dish machine hood ventilation system was rust-laden, despite a previous citation for the same issue. The Accounts Manager/Food Service Director admitted that the vent should be cleaned daily. Even after an attempt to clean the vent, rust was still present. These deficiencies in food storage, labeling, and equipment maintenance have the potential to affect one-hundred and thirty-two out of one-hundred and forty-two residents who consume food orally in the facility.
Failure to Document Advance Directives for Residents
Penalty
Summary
The facility failed to provide advance directives documentation for seven out of seven sampled residents. Record reviews for Residents #102, #137, #305, #307, #65, #76, and #77 showed no written documentation related to advance directives. Interviews with the Administrator, Social Services Director, and Admission Director revealed that while advance directives are part of the admission package, there is no documentation confirming that residents or their representatives were offered and declined to execute these directives. The facility's policy requires that any existing advance directives be included in the medical record, but this was not followed for the sampled residents. The Social Services Director and Admission Director confirmed that advance directives are explained to residents or their representatives upon admission, and they are informed to bring any existing documents to the facility. However, there is no signed documentation indicating that residents were offered advance directives and chose not to execute them. This lack of documentation was acknowledged by the Administrator and Social Services Director during interviews, indicating a systemic issue in the facility's process for handling advance directives.
Failure to Implement Effective QAPI Program
Penalty
Summary
The facility failed to ensure an effective Quality Assessment and Assurance (QAA) committee/Quality Assurance/Performance Improvement (QAPI) program, as evidenced by not implementing corrective plans of action for repeated deficiencies. These deficiencies were related to the labeling and storage of drugs and biologicals, sanitary food handling, and infection control. The facility's survey history revealed that these issues were previously cited during the last recertification survey. Despite having a QAA committee that meets monthly and includes various key staff members, the facility did not address these repeated deficiencies effectively. During an interview, the Administrator mentioned that the committee has Performance Improvement Plans (PIPs) in place, such as those for decreasing falls, but did not provide evidence of effective plans for the cited deficiencies. The facility's policies and procedures outline a comprehensive QAPI plan, but the repeated citations indicate a failure to implement these plans effectively. At the time of the survey, there were 142 residents residing in the facility, potentially at risk due to these ongoing issues.
Improper Disposal of Biohazard Material
Penalty
Summary
The facility failed to properly dispose of biohazard material for one resident. During a wound care observation, a CNA disposed of a biohazard trash bag into a bin with a white lid instead of the designated biohazard box. The CNA admitted to placing the bag in the wrong bin due to nervousness and later corrected the mistake by moving the bag to the proper biohazard container. This incident was observed and documented by surveyors, who noted the improper disposal of biohazard material in the soiled utility room. The Director of Nursing confirmed that all materials containing blood or body fluids should be placed in a biohazard bag and then into a box labeled Biohazard. The facility's policy on waste disposal, dated October 2019, mandates that all infectious and regulated waste be handled in a safe and appropriate manner, using color-coded or labeled containers. The policy also specifies that the Infection Preventionist and the environmental services director are responsible for ensuring proper waste disposal. Despite this policy, the CNA's error in disposing of the biohazard bag led to a deficiency in infection control practices.
Dish Machine Temperature Deficiency
Penalty
Summary
The facility failed to ensure the high temperature dish machine for the wash cycle and the final rinse cycle was working properly. Observations revealed that the wash dial was at 150 degrees Fahrenheit and the final rinse dial was at 174 degrees Fahrenheit, which did not meet the required temperatures of 160 degrees Fahrenheit for the wash cycle and 180 degrees Fahrenheit for the final rinse cycle. This issue was observed during multiple cycles, indicating a consistent problem with the dish machine's temperature regulation. Interviews with the Accounts Manager/Food Service Director and Staff A, Dietary Aide, confirmed that the dish machine was not reaching the required temperatures. The Accounts Manager/Food Service Director noted that the dish machine log for breakfast showed different temperatures, which were also incorrect. The issue was identified to be caused by a knife stuck in the dish machine drain, which was later resolved by a technician. However, the deficiency was present at the time of the survey, affecting the sanitation of dishware for the residents who eat orally in the facility.
Failure to Provide Dignity During Meal Assistance
Penalty
Summary
The facility failed to provide dignity while dining for one resident, as evidenced by a CNA standing while assisting the resident to eat breakfast. The observation occurred on 04/24/2024 at 8:46 AM, where Staff E, a CNA, was seen standing while assisting Resident #27. The resident had been admitted with a diagnosis that included morbid obesity and had a care plan initiated for potential nutritional problems, which included assistance with meals. The CNA acknowledged awareness of the facility's protocol to be seated while assisting residents but cited the bed height as a reason for standing. The Director of Nursing confirmed that staff are required to be seated next to residents while assisting with meals to provide dignity. The facility's policy on dignity, dated 12/2017, mandates treating each resident in a manner that promotes their quality of life, including being seated while assisting with eating. The failure to follow this protocol was observed and confirmed through staff interviews and record reviews, highlighting a deficiency in maintaining resident dignity during meal assistance.
Inaccurate MDS Coding for Resident Discharge
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for a resident who was discharged. Specifically, the MDS for one resident indicated that the resident was discharged to a hospital, while the resident was actually discharged to home. This discrepancy was identified during a review of the resident's records, which showed that the resident was admitted to the facility and later discharged home in stable condition. The resident's care plan also indicated that the resident wished to be discharged to home with a sister-in-law, and the discharge summary confirmed that the resident was discharged home with signed discharge instructions. The error was acknowledged by the MDS Coordinator during an interview, who stated that it was an oversight and would be corrected immediately. The facility's policy on Resident Assessment Instrument (RAI) emphasizes the importance of accurate and comprehensive documentation of the MDS to ensure proper assessment and care planning for residents. However, in this instance, the policy was not adhered to, resulting in inaccurate coding of the resident's discharge status.
Failure to Maintain Accurate Controlled Drug Records
Penalty
Summary
The facility failed to maintain accurate drug records for controlled substances, specifically for a resident's Clonazepam 0.5 mg tablets. During a narcotic count, it was observed that the blister pack contained 33 tablets, while the Controlled Drug Receipt/Proof of use/Disposition form indicated 34 tablets. The discrepancy was noted on 04/24/24, with the last recorded administration on 4/23/2024. The electronic medication administration record showed that the medication was administered on 4/24/2024 at 1:16 PM, but the nurse, Staff C, admitted to forgetting to sign the form after administering the medication due to being distracted. The Director of Nursing confirmed that nurses are required to sign out controlled medications on the appropriate form at the time of removal from the blister pack. The facility's policy on controlled drugs, dated 10/2017, mandates special handling, storage, disposal, and record-keeping for Schedule II, III, and IV drugs. The policy specifies that a control sheet must be maintained for each substance, including the number on hand, time of administration, and the signature of the administering nurse. The failure to adhere to these procedures led to the observed discrepancy in the controlled drug records.
Improper Medication Storage
Penalty
Summary
The facility failed to properly store medications for one resident, as evidenced by the observation of medication in the resident's room without staff present. During a survey, two small, white, circular tablets were found inside a transparent medicine cup on a side table next to the resident's bed. The resident stated that the medication was given by the overnight nurse and kept due to not wanting to take it on an empty stomach. The LPN on duty was unaware of any medication being administered to the resident and confirmed that the resident was not approved to self-medicate. Facility protocol requires that any found medication be retrieved, the resident educated, the medication disposed of, and the supervisor notified, which was followed in this instance after the surveyor's observation. The resident involved had a diagnosis of Systemic Lupus Erythematosus and was cognitively intact with a BIMS score of 14. The resident's care plan included interventions for pain management related to lupus, depression, weakness, and decreased mobility. The resident had a physician's order for Acetaminophen 325 mg to be taken as needed for pain. The facility's policy on medication storage mandates that drugs and biologicals be stored in a safe, secure, and orderly manner, and no residents are allowed to have medications in their rooms without staff present. The Director of Nursing confirmed that no residents in the facility are approved to self-medicate and that education is provided to prevent unauthorized medication in resident rooms.
Failure to Ensure Splint Device Usage for Contracture Management
Penalty
Summary
The facility failed to ensure that a splint device was in place to prevent worsening of left hand and left elbow contractures for a resident. Multiple observations over several days revealed that the resident, who had contractures on both elbows and hands, was not wearing the prescribed hand rolls or splints. Despite a physician's order for the resident to wear a left grip hand splint and left elbow contracture management splint daily, these devices were not observed on the resident during the survey period. The resident, who has a history of multiple sclerosis, diabetes mellitus, functional quadriplegia, and contractures, was admitted to the facility in 2016 and had recently returned from a hospital stay. The resident's care plan, which was revised in February 2024, did not include interventions with splints, despite the resident's significant contractures. Interviews with staff indicated that the resident had only started wearing the splint on 4/23/2024, and even then, it was only tolerated for a few hours per day. The Director of Rehab confirmed that the resident was evaluated and prescribed the splints on 4/23/2024, but the resident had not been wearing them consistently. The facility's policy on assistive devices and equipment requires that all residents be screened and evaluated for appropriate rehab equipment upon admission, transfer, or return. However, this policy was not adequately followed, leading to the deficiency in the resident's care.
Failure to Prevent Fecal Impaction Leading to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident was free from abuse and neglect, resulting in the resident's death due to fecal impaction. The resident, who had multiple clinical diagnoses including cachexia, anorexia, and dementia, was admitted to the facility and had orders for medications to manage constipation. Despite these orders, the facility staff did not adequately monitor or document the resident's bowel movements, leading to severe constipation and fecal impaction. The resident was found hypotensive and hypothermic upon arrival at the hospital and was diagnosed with septic shock, fecal impaction of the colon, metabolic acidosis, and a closed traumatic brain injury, ultimately leading to the resident's death. The resident's care plans indicated a risk for constipation and included interventions such as encouraging fluids, monitoring medications, and documenting bowel movements. However, the facility staff failed to implement these interventions effectively. The last documented bowel movement was several days before the resident's fall, and there was no follow-up to ensure the resident's bowel health was maintained. The resident's condition deteriorated, leading to a fall and subsequent transfer to the hospital, where the severe complications were identified. Interviews with facility staff revealed inconsistencies in monitoring and documenting the resident's bowel movements. The Director of Nursing and other staff members acknowledged that the resident was independent but required assistance at times. Despite this, the staff did not adequately track the resident's bowel movements or respond to signs of constipation. The facility's policy on preventing abuse and neglect was not followed, resulting in the resident's severe health decline and eventual death.
Failure in Bowel Management Leads to Resident's Death
Penalty
Summary
The facility failed to ensure that a resident received care and treatment in accordance with professional standards of practice related to bowel management. The resident, who had a history of cachexia, anorexia, nutritional anemia, type 2 diabetes mellitus, and disease of the esophagus, was found to have a fecal impaction upon admission to the hospital. The resident's care plan included interventions for constipation, but these were not adequately followed, leading to the resident's hospitalization and subsequent death due to complications from fecal impaction and septic shock. The resident's medical records indicated that the last documented bowel movement was several days before the incident. Despite having orders for medications to manage constipation, there was a lack of consistent monitoring and documentation of the resident's bowel movements. The facility's bowel protocol, which included steps to be taken when a resident had not had a bowel movement for three days, was not effectively implemented. Interviews with staff revealed that while they were aware of the protocol, there was a failure in communication and documentation, leading to the resident's condition being overlooked. On the day of the incident, the resident was found pale and lethargic after falling from a wheelchair. Despite being assessed and transferred to the hospital, the resident's condition deteriorated, and she was diagnosed with septic shock, fecal impaction, metabolic acidosis, and a closed traumatic brain injury. The facility's failure to adhere to its bowel management protocol and adequately monitor the resident's condition contributed to the resident's severe health decline and eventual death.
What surveyors are citing around you — mapped
All 10 risk areas, ranked with evidence
Repeat citations, what's rising near you, and quality measures — ranked so department heads know exactly where to look first.
Illustrative
What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
Illustrative
A prioritized, do-first checklist
Every risk area becomes concrete audit steps drawn from real citations at facilities like yours — run them this week, before your window opens.
Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Homestead
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Homestead Manor A Palace Community | 2.4 mi | ★★★★★ | 0 | 0 |
| Kendall Lakes Healthcare And Rehab Center | 7.9 mi | ★★★★★ | 0 | 0 |
| St Annes Nursing Center, St Annes Residence Inc | 9.9 mi | ★★★★★ | 4 | 0 |
| East Ridge Rehabilitation And Nursing Center | 11.6 mi | ★★★★★ | 5 | 0 |
| Jackson Memorial Perdue Medical Center | 11.8 mi | ★★★★★ | 5 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.