Above average — CMS composite of the measures below.
A standard survey is most likely before around December 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 Brown Health And Rehabilitation during CMS and state inspections, most recent first.
Failure to timely report resident-on-resident sexual abuse: A CMA observed a male resident grab a female resident's breast and moved the resident away, but the incident was not reported to the SSA within the required timeframe. Facility policy required immediate reporting of abuse to the Administrator or supervisor, and the CMA later could not recall exactly who she told about the incident.
Infection control procedures were not followed during medication passes when CMAs used paper towel barriers on medication carts and did not change them between residents. One CMA administered medications to multiple residents in Dining Room Three without changing the barrier, and another CMA did the same for a resident before moving to the next room. The DON confirmed staff were expected to change barriers between residents to prevent cross contamination.
The facility failed to prevent the spread of infection by using cracked and peeling foam protectors over bed rails, creating uncleanable surfaces for four residents. The foam, secured with duct tape, was confirmed by the Infection Preventionist to harbor bacteria due to its porous texture.
The facility failed to complete and electronically transmit Discharge MDS assessments for two residents discharged to home, as required by the RAI Manual. The MDS Coordinator confirmed the oversight, and the Administrator and DON acknowledged the expectation for compliance.
The facility failed to update the care plan for a resident when a pacemaker monitoring device was provided and did not ensure another resident was invited to participate in their quarterly care plan meetings. Staff were unaware of the device's purpose, and the care plan lacked necessary documentation. Additionally, the resident with moderate cognitive impairment was not invited to care conferences, contrary to facility policy.
A resident with cerebral palsy and morbid obesity fell from a mechanical lift sling when the upper right strap broke during a transfer. The facility failed to inspect the sling for damage after laundering, as required by policy and manufacturer guidelines. The resident complained of pain and was sent to the hospital but did not suffer any injuries. Staff interviews revealed that the inspection process was not documented before the incident.
The facility failed to educate staff about a remote cardiac monitor for a resident with a pacemaker, leading to a deficiency in ensuring appropriate care and monitoring for cardiac instability. The device was brought in by the resident's family, but staff were not informed or trained on its use.
The facility failed to conduct thorough investigations into allegations of potential sexual abuse involving two residents. The investigations lacked interviews with the victim, other staff, and residents, and did not include staff witness statements, despite the facility's policy requiring these steps.
Failure to Timely Report Resident-on-Resident Sexual Abuse
Penalty
Summary
The facility failed to protect a resident from sexual abuse by another resident by not reporting the incident to the State Survey Agency within the required timeframe. According to the report, Certified Medication Aide JJ told the Administrator during a resident care meeting that she had observed a male resident inappropriately touch R85 several months earlier. CMA JJ stated she did not remember the exact date, but recalled hearing R85 giggling and then seeing the male resident reach across and grab R85's breast. CMA JJ said she told the male resident to stop immediately and moved R85 away. The facility policy titled Abuse Prohibition stated that any person observing abuse, neglect, or exploitation should immediately report it to the Administrator or direct supervisor present at the time of the incident. The Five-Day follow-up noted that CMA JJ could not remember who she had told about the incident and that she received 1:1 education regarding immediately reporting to the Administrator as Abuse Coordinator. The Administrator later confirmed that CMA JJ was no longer employed by the facility and that staff received regular in-services related to abuse and abuse reporting.
Infection Control Failure During Medication Pass
Penalty
Summary
The facility failed to ensure proper infection control procedures were followed during medication administration for four residents, creating cross-contamination. The facility’s Infection Prevention Plan stated that policies, procedures, and aseptic practices are to be followed by personnel when performing procedures and disinfecting equipment. On 9/10/2025 at 8:25 a.m., CMA AA was observed administering medications to R5 in Dining Room Three with a paper towel placed on the medication cart as a barrier, then proceeded to administer medications to R11 and R1 without changing the barrier. During interview at 9:00 a.m., CMA AA confirmed she used a barrier on the medication cart and did not change it between residents, and stated it should have been changed between residents. On 9/10/2025 at 8:44 a.m., CMA BB was observed administering medications to R78 with a paper towel taped to the medication cart surface as a barrier, then completed the medication pass and went to the next room without changing the barrier. CMA BB confirmed the barrier was not changed between residents. At 9:26 a.m., the DON confirmed nursing staff were expected to change barriers between residents during medication administration to prevent cross contamination.
Infection Control Deficiency Due to Uncleanable Foam Padding on Bed Rails
Penalty
Summary
The facility failed to ensure the prevention of the spread of infection by using foam protectors in disrepair over bed rails, creating an uncleanable surface for four residents. The foam padding on the side rails was cracked, peeling, and secured with duct tape, which exposed porous areas that could harbor bacteria. This issue was observed in the rooms of residents with various diagnoses, including rheumatoid arthritis, chronic pain syndrome, Alzheimer's disease, amnesia, and dementia. The care plans for these residents lacked documentation indicating the need for padded side rails. During interviews, the Director of Nursing (DON) and the Maintenance Director revealed a lack of understanding of the infection control concern related to the foam padding. The foam was acquired from a hardware store, cut to size, and secured with tape to the bed rails. The Infection Preventionist (IP) confirmed that the foam was not cleanable due to its porous texture, which could lead to the spread of bacteria among residents and staff. Residents and staff were unaware of the reasons for the foam padding, and the foam had been in place for extended periods. The facility's policy on standard patient room cleaning required the disinfection of surfaces in the patient's zone, including bed rails, but the foam padding's condition made it impossible to clean effectively. This deficiency had the potential to harbor bacteria and spread infection to the residents.
Failure to Complete and Transmit Discharge MDS Assessments
Penalty
Summary
The facility failed to complete and electronically transmit a Discharge Minimum Data Set (MDS) assessment to CMS's Quality Improvement Evaluation System (QIES) Assessment Submission and Processing (ASAP) system for two residents who were discharged to home. According to the Resident Assessment Instrument (RAI) Manual, a Discharge assessment is required for residents discharged from the facility to a private residence. However, for Resident 35, who was discharged home on 12/21/2023, and Resident 80, who was discharged home on 11/27/2023, there was no evidence of a discharge assessment completed to indicate that they would not return to the facility. During interviews, the MDS Coordinator confirmed that both residents should have had an OBRA discharge MDS assessment to indicate their discharge status. The Administrator and Director of Nursing also stated that it was their expectation that all mandatory MDS assessments be completed and transmitted per RAI requirements. The lack of completed discharge assessments for these residents constitutes a deficiency in the facility's compliance with regulatory requirements.
Failure to Update Care Plan and Involve Resident in Care Planning
Penalty
Summary
The facility failed to update the care plan for a resident (R31) when a pacemaker monitoring device was provided. Despite the presence of the device in the resident's room, staff were unaware of its purpose, and the care plan lacked documentation regarding the device. Interviews with the LPN, RN, ADON, and DON confirmed that the care plan should have been updated to include the monitoring device when it was brought into the facility. This oversight was identified during a review of the resident's medical records and care plan, which did not reflect the necessary interventions for the pacemaker monitoring device. Additionally, the facility failed to ensure that another resident (R1) was invited to participate in their quarterly care plan meetings. Despite having moderate cognitive impairment, the resident was not invited to the care conferences, as confirmed by interviews with the resident, the Social Services Director, and the MDS Coordinator. The facility's policy required that residents and their representatives be invited to care planning conferences, but this was not adhered to in R1's case. These deficiencies were identified through interviews, record reviews, and observations, highlighting the facility's failure to update care plans based on changing needs and to involve residents in their care planning process. The sample size for the investigation was 41 residents, and these failures had the potential to impact the care and services provided to the residents involved.
Failure to Inspect Mechanical Lift Sling Leads to Resident Fall
Penalty
Summary
The facility failed to ensure a mechanical lift sling was inspected for damage and defects after laundering, leading to a fall incident involving a resident with cerebral palsy and morbid obesity. The resident, who was cognitively intact and dependent on staff for transfers, fell from a mechanical lift sling when the upper right strap broke during a transfer from a motorized wheelchair to the bed. The incident occurred despite the facility's policy and manufacturer guidelines requiring slings to be inspected for wear and damage after washing. The resident complained of pain and was sent to the hospital but did not suffer any injuries. Interviews with the facility's staff revealed that the laundry staff did not document inspections of mechanical lift slings for defects or damage before putting them back in circulation. The Housekeeping Supervisor confirmed that the inspection process was not in place until after the incident. The Administrator acknowledged that the cause of the broken sling could not be determined, but the investigation highlighted the lack of documented inspections. Following the incident, the facility implemented a new process to inspect and document the condition of slings after laundering.
Lack of Staff Training on Cardiac Monitor
Penalty
Summary
The facility failed to ensure staff were informed or educated about the remote cardiac monitor's purpose for a resident with a pacemaker monitor. The resident, who had severe cognitive impairment and diagnoses including sick sinus syndrome, left bundle branch block, and heart failure, had a remote cardiac monitor in their room. The device was brought to the facility by the resident's family member after a cardiology appointment to monitor the pacemaker due to a low battery. However, the facility's staff, including the Licensed Practical Nurse (LPN) providing care for the resident, were not aware of the device's purpose or how to use it. The Director of Nursing (DON) confirmed that no education was provided to the staff regarding the device when it was brought into the facility. The Assistant Director of Nursing (ADON) and another LPN also acknowledged that the device was set up without informing or training other staff members. The facility's assessment and care plan did not include information about the cardiac pacemaker monitoring equipment or the necessary staff training for its use, leading to a deficiency in ensuring the resident received appropriate care and monitoring for cardiac instability.
Failure to Conduct Thorough Abuse Investigations
Penalty
Summary
The facility failed to complete a thorough investigation for two residents (R48 and R82) regarding allegations of potential sexual abuse. Specifically, the facility did not interview R48, the victim, or other staff and residents as part of the investigations. The facility's policy on abuse prohibition and investigation requires interviews with pertinent parties and obtaining written signed statements or witnessed, signed interviews. However, there was no evidence that these steps were followed in the investigations of incidents on 3/6/2024 and 3/18/2024. The facility's investigation documents did not include staff witness statements or interviews with R48, despite the resident being cognitively intact according to an earlier assessment. R82, who has a diagnosis of dementia and severe cognitive impairment, was involved in both incidents where he kissed R48 on the cheek. In the first incident, R82 was observed kissing R48, and the facility conducted a BIMS assessment for R48, which showed severe cognitive impairment. Both residents were separated, but no interviews were conducted with other staff or R48. In the second incident, R82 kissed R48 again, and staff immediately intervened. R82 was sent for a psychiatric evaluation and returned to the facility. Despite these actions, the facility did not interview other staff or R48 as part of the investigation, and no staff witness statements were documented in the clinical records for both incidents.
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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.
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Nursing homes near Royston
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Comer Health And Rehabilitation | 11 mi | ★★★★★ | 4 | 0 |
| Hartwell Health And Rehabilitation | 11.1 mi | ★★★★★ | 7 | 0 |
| Hart Care Center | 12.3 mi | ★★★★★ | 0 | 0 |
| Pruitthealth - Spring Valley | 18 mi | ★★★★★ | 1 | 0 |
| Northridge Health And Rehabilitation | 20.5 mi | ★★★★★ | 0 | 0 |
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