Average — CMS composite of the measures below.
The next survey window likely opens around April 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brooke Grove Rehab. & Nsg Ctr during CMS and state inspections, most recent first.
A resident was observed still waiting to eat breakfast while the roommate had already received a tray about an hour earlier. The resident said they were hungry, and the roommate reported that no staff had come to feed the resident yet. A GNA arrived with the tray only as the surveyor was leaving, and the UM stated that residents needing feeding are served last after trays are delivered to the unit.
Failure to assess a resident’s ability to self-administer meds and to document a person-centered care plan. A resident with a BIMS of 15/15 and no upper-extremity impairment was observed holding multiple pills and taking meds slowly, one at a time, while an LPN checked back intermittently. The EMR and care plan lacked documentation of a self-administration assessment or which meds were safe for the resident to take independently.
A resident did not receive the required SNF ABN (CMS-10055) or NOMNC (CMS-10123) coverage notices. Facility records showed both forms should have been issued, and the DOSS confirmed they were not provided.
A resident repeatedly reported excessive unit noise that disrupted rest and sleep, including furniture dragging and staff laughing, joking, and singing loudly near the room. Surveyors also observed loud hallway conversation, equipment movement, an ignored beeping fire alarm at the nursing station, and a CNA singing loudly, showing ongoing noise that did not support a quiet, home-like environment.
The facility failed to notify the local Ombudsman of hospital transfers for two residents. One resident was hospitalized after an abnormal abdominal x-ray, and another resident was transferred to the hospital, but neither resident was included on the facility’s monthly admissions/discharges reports sent to the Ombudsman. The NHA stated the facility had been treating the reports as covering discharges and deaths only, not hospital transfers.
PASARR Not Updated to Reflect Resident Mental Health Status: The facility failed to review and revise a resident's PASARR after admission to reflect current status. A resident admitted with dementia, hallucinations, anxiety disorder, and major depressive disorder had a PASARR Level I that did not identify major mental illness, related symptoms, or psychotropic medication use. During survey review, the SWD acknowledged that PASARRs are to be reviewed for inaccuracies after admission, but the resident's documentation remained inaccurate.
Delayed Medication Administration: A resident reported that medications were frequently given late, especially on the evening shift, and also stated that morning meds due at 8:00 AM had not yet been received. MAR and audit review showed multiple scheduled meds, including antihypertensives, gabapentin, sulfasalazine, pancreatic enzymes, and other ordered medications, were administered well outside the facility’s 1-hour window, with several doses given more than 2 hours late and one dose after midnight.
Failure to provide personalized activity engagement: Two residents were observed without meaningful in-room activity support, with one resident dozing in a wheelchair and another asleep in bed while no activity staff were present. Records showed low rates of documented one-to-one visits compared with the expected daily visits, and no self-stimulation materials or devices were available for one resident. Both residents had care plans calling for frequent in-room engagement and individual discovery, and one resident expressed a desire for more creative options.
A resident admitted after a fall with a C2 cervical fracture and cervical subluxation did not have the ordered Aspen neck collar and related monitoring entered right away. The baseline care plan did not identify the brace need, and staff acknowledged the omission was missed during admission despite the hospital discharge instructions and the resident reporting the brace was uncomfortable. The DON, Administrator, and Admissions Nurse confirmed the order delay and documentation gaps.
A resident received Aldactone for CHF despite BP parameters that required the dose to be held when diastolic BP was below 60. The MAR showed the medication was administered even though the resident’s BP was 115/50, and the DON confirmed the nurse did not follow the order parameters.
Food temperature logs were missing for multiple meal services, and the tray line was observed being plated without complete documentation of temperatures. The surveyor also found expired food items, thickened beverages past discard dates, and multiple opened or stored food items in the main kitchen and rehab satellite kitchens that were unlabeled or improperly stored. The Exec Chef and Interim CDM acknowledged the findings.
Laundry Area Not Maintained in Sanitary Condition: Surveyors observed a personal iPad, staff belongings, food, drinks, and a makeshift eating area in the laundry service area. On follow-up, three drink cups were found hidden behind a sewing machine, and a laundry tech رفضed the policy prohibiting drinks in the area. The Administrator acknowledged the staff’s non-cooperative behavior and the presence of personal items and eating areas in the laundry room.
Surveyors found that MDS assessments were inaccurately coded for two residents. In one case, a resident sustained a femoral neck fracture after a fall, but the subsequent significant change MDS did not code the fall as a major injury and failed to capture prn Tylenol use documented on the MAR within the look-back period. In the other case, a quarterly MDS indicated opioid use for a resident, but the MAR for the same period showed no prescribed opioid, indicating incorrect coding of high-risk drug classes.
A resident who had recently been admitted and experienced a fall received multiple doses of the narcotic analgesic Tramadol, but the facility failed to accurately document all administered doses on the Medication Administration Record (MAR). Review showed only one Tramadol dose recorded on the MAR, while the Controlled Drug Receipt/Record/Disposition Form on the med cart reflected three doses given over two days. In interview, the DON stated staff are expected to document narcotic administration on the MAR and confirmed that two administered doses were not recorded there, resulting in an incomplete and inaccurate medical record.
Delayed Assistance With Breakfast Feeding
Penalty
Summary
The facility failed to ensure resident dignity during mealtimes for Resident #148. On 5/21/2026 at 10:11 AM, the surveyor observed that the resident had not yet eaten breakfast and stated they were hungry. The roommate reported receiving breakfast around 9:00 AM and said no one had come in to feed Resident #148. As the surveyor was leaving, the GNA arrived with the tray to feed the resident. The UM explained that the GNA had been assisting another resident who had a bowel movement and that residents who need to be fed are served last after trays are delivered to the unit between 8:00 and 8:30 AM. The NHA was later notified of the concern that the resident was fed about an hour after the roommate, which was identified as a dignity issue.
Failure to Assess Safe Self-Administration of Medications
Penalty
Summary
The facility failed to assess whether a resident could safely self-administer medications and failed to develop and implement a person-centered care plan for self-administration. During an initial tour of the 1st floor rehab unit, the resident was observed holding a white paper medicine cup containing multiple pills and stated that they like to take their pills slowly, one at a time, and that the nurse would come back to check on them. An LPN was then seen entering the room. Review of the resident’s MDS comprehensive assessment showed a BIMS score of 15/15, indicating the resident was cognitively intact with no functional impairment of the upper extremities. However, the electronic medical record and care plan did not contain documentation showing the resident had been assessed for safe self-administration or identifying which medications could be safely self-administered. An LPN stated the resident received stool softeners, a probiotic, and Vitamin D in the mornings, took medications slowly over more than an hour, and was capable of taking medications safely while being checked on multiple times. The DON stated that residents should be assessed for the capacity to self-administer medication, have a physician’s order, and have a person-centered care plan for safe medication administration.
Failure to Provide Required Medicare Non-Coverage Notices
Penalty
Summary
Medicare beneficiaries were not given required coverage notices for Resident #33, as the facility failed to provide both the Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (CMS-10055) and the Notice of Medicare Non-coverage (CMS-10123). Record review of the facility’s SNF Beneficiary Protection Notification Review form showed that Resident #33 was not issued the CMS-10055 form, and the facility marked that it should have been issued. The same review showed that Resident #33 was also not issued the CMS-10123 form, with the facility again indicating that it should have been provided. During interview, the DOSS confirmed that both forms were not provided to the resident even though they should have been.
Failure to Maintain a Quiet, Home-Like Environment
Penalty
Summary
The facility failed to ensure a resident's right to a quiet, home-like environment for Resident #159, who repeatedly reported ongoing noise that interfered with rest and sleep. The resident described continued sounds of furniture being dragged and staff laughing, joking, and singing loudly near the room, and the surveyor personally observed loud conversation and laughing from staff in the hallway that could be heard from inside the resident's room. The noise concerns persisted over multiple observations and interviews. The Unit Manager acknowledged awareness of the complaints, but later observations still found high noise levels on the unit, including staff moving equipment, a fire alarm beeping at the nursing station that had reportedly been ignored for several hours, and a nursing aide singing loudly in the hallway. The report states that these consistently high noise levels did not support the resident's right to a quiet, home-like environment or resident-centered care.
Failure to Notify Ombudsman of Hospital Transfers
Penalty
Summary
The facility failed to ensure the local Ombudsman was notified of resident transfers to the hospital for 2 of 5 residents reviewed for hospitalizations. One resident was hospitalized after an abnormal abdominal x-ray, but the resident’s name was not included on the facility’s Admissions/Discharges list that was emailed to the local Ombudsman. During interview, the Nursing Home Administrator stated that the resident had been transferred to the hospital and returned the next day, but was not included because the facility considered the list to cover discharges and deaths rather than hospital transfers. A second resident was transferred to the hospital, but the resident was also omitted from the facility’s monthly Discharges report that was emailed to the local Ombudsman. The surveyor confirmed with the Nursing Home Administrator that the resident had been left off the report, and the administrator stated that the facility had not been including hospital transfers on the monthly reports sent to the local Ombudsman.
PASARR Not Updated to Reflect Resident Mental Health Status
Penalty
Summary
The facility failed to ensure a resident's PASARR was reviewed after admission and revised to reflect the resident's current status. Resident #113 was admitted with diagnoses including dementia, hallucinations, anxiety disorder, and major depressive disorder. A review of the resident's PASARR Level I, completed by the hospital prior to admission, showed that it did not identify known or suspected major mental illness, signs or symptoms of major mental illness, or the use of an antipsychotic, mood stabilizing, or antidepressant medication. During the survey, the Social Work Director stated that PASARR Level I screenings are completed by hospital staff prior to admission and that social work staff are responsible for reviewing and updating the PASARR if inaccuracies are found after admission. The surveyor identified that the resident's PASARR did not reflect the resident's documented mental health diagnoses and related indicators. A later review of another resident's PASARR documentation also confirmed inaccurate documentation of resident status, and the facility had not ensured the PASARR was reviewed after admission and revised as needed to reflect current status.
Delayed Medication Administration
Penalty
Summary
The facility failed to administer medications in a timely manner and according to professional standards of practice for one resident on the 1st floor rehab unit. During an interview, the resident stated that medications were frequently given late, particularly during the evening shift. A review of the resident’s MAR and Medication Admin Audit Report showed multiple medications documented as administered well beyond the facility’s stated expectation of within 1 hour before or 1 hour after the prescribed time, including several evening doses given more than 2 hours late and one dose given after midnight when scheduled for 8:00 PM. The record review identified repeated late administration of scheduled medications such as Olmesartan Medoxomil, Labetalol HCl, sulfasalazine, pancreatic enzymes, Gabapentin, Tenapanor HCl, MiraLax, Lysine, Lidocaine patch, and HydrALAZINE HCl. The resident also stated on another occasion that morning medications due at 8:00 AM had not yet been received. During interview, the DON stated the facility expectation was medication administration within 1 hour before or after the prescribed time, and the surveyor confirmed instances where the resident’s medications were administered outside that timeframe.
Failure to Provide Personalized Activity Engagement
Penalty
Summary
The facility failed to provide ongoing personalized activities to meet residents’ physical, mental, and psychosocial needs for 2 of 5 residents reviewed. Resident #15 was observed in the room dozing in a wheelchair, and there was no evidence that activity staff provided one-to-one interaction, personalized activities, or any device or materials for the resident to use. The resident attended group activities only occasionally and expressed a desire for more suitable options focused on creativity. The resident’s diagnoses included schizoaffective disorder, depression, hypoxia, and diverticulitis, and the activity plan called for in-room engagement and individual discovery five to six times per week. Resident #7 was observed in the room, falling asleep while sitting up in bed during a three-hour observation period, with no activity staff present. A room check found no self-stimulation activities, materials, or devices in the room. The resident had limited verbal language skills but could communicate needs by answering yes and no questions, and indicated yes to getting out of bed for activities and no to activity staff visits. The resident’s diagnoses included dementia, right rib fracture, cellulitis, pulmonary embolisms, heart failure, and acute kidney failure, and the activity plan called for in-room engagement and individual discovery five to six times per week. Record review showed low frequencies of documented one-to-one visits for both residents compared with the expected daily visits described by the Activity Director.
Delayed Neck Brace Order and Care Planning
Penalty
Summary
The facility failed to ensure post-surgical care recommendations were timely implemented and monitored for a resident admitted after a fall with a C2 cervical fracture and cervical subluxation. The resident’s hospital discharge summary documented that the orthopedic surgeon recommended the hard neck collar be worn until an outpatient follow-up appointment within two weeks of discharge. On admission, the resident was observed in bed wearing a neck brace with facial injuries present, and the nursing admission assessment documented the cervical fracture and hard collar requirement. Review of the medical record showed the neck brace order was not entered until several days after admission, and the baseline care plan did not identify the resident’s neck brace/collar as an immediate care need. The surveyor also found that the resident had reported the cervical brace was uncomfortable and bothering them, prompting a communication to the on-call provider. The provider responded that physical therapy should see the resident for brace adjustment if indicated and that follow-up with the specialist who recommended the brace should be scheduled. During interviews, the Administrator, DON, and Admissions Nurse acknowledged that the order had not been entered on admission and that the omission was missed during the admission process. The Administrator stated the admitting nurse, supervisor, and night shift should have checked that the care and orders were correct, and confirmed that orders surrounding a neck brace should be in place right away. The resident’s neck brace order, monitoring for skin breakdown and complications, and related monitoring orders were not implemented until after the delay was identified.
Medication Given Outside Ordered BP Parameters
Penalty
Summary
The facility failed to ensure medication order parameters were followed and failed to ensure a resident was free from unnecessary medication. For Resident #178, the medical record showed an order for Aldactone 25 mg by mouth in the afternoon for CHF with instructions to hold the dose for systolic BP less than 110 or diastolic BP less than 60. Review of the May 2026 MAR showed the medication was administered on 5/14/26 despite a documented BP of 115/50, which was outside the ordered parameters. During interview, the DON stated that Nurse #13 did not follow the parameters and confirmed that the medication was given to the resident outside the ordered limits.
Food Temperature Logs Missing and Food/Drink Storage Not Properly Labeled
Penalty
Summary
The facility failed to maintain food temperature logs and failed to store, prepare, distribute, and serve food in accordance with professional standards. During observation of the main kitchen, the surveyor saw the tray line being plated for resident meal service, and review of the food temperature log binder did not show recorded temperatures for breakfast and lunch on 5/16/2026, breakfast and lunch on 5/17/2026, or breakfast on 5/18/2026. The Executive Chef confirmed that food temperatures are taken while food is on the food table and then recorded in the binder for each meal service. The surveyor also observed multiple food and drink storage concerns in the main kitchen and satellite kitchens. In the main refrigerator, items were found past their discard dates, including coleslaw, pureed prep, and shrimp. In the hydration refrigerator, thickened orange juice and thickened cranberry juice were labeled with dates indicating they should have been discarded 7 days after opening, but the cartons were labeled 4/18-4/28. In the pantry, a white powdery substance was left open to air, several large mobile food storage containers held unlabeled white powdery substances, and another container held a tan crumb substance with an unlabeled gallon storage bag of white powdery substance inside. In the 1st floor rehab satellite kitchen, opened thickened apple juice and thickened lemon-flavored water had no labels. In the 2nd floor rehab satellite kitchen, opened almond milk had no label, and several thickened beverages were labeled 5/9/2026 despite carton instructions to discard 7 days after opening. The Interim CDM acknowledged the findings.
Laundry Area Not Maintained in Sanitary Condition
Penalty
Summary
The facility failed to maintain proper infection prevention and control practices in the laundry service area. During a tour of the laundry service area, a personal iPad in a small old shopping bag was observed on a side table in the washing room, the top shelves of the dryer room were filled with staff personal belongings, food, and drinks, and a makeshift eating area was set up within the dryer room. On a follow-up tour of the laundry service area, three drink cups were found hidden behind a sewing machine belonging to a laundry tech. When the Housekeeping Director addressed the cups, the laundry tech stated it was ridiculous to follow the policy prohibiting drinks in the laundry service area. The Administrator later acknowledged that staff personal items were stored throughout the laundry service area, an eating area was present in the dryer room, and the non-cooperative behavior of the laundry staff was unacceptable after education on laundry service regulations and policies had already been provided.
Inaccurate MDS Coding for Falls, Pain Management, and High-Risk Medications
Penalty
Summary
Facility staff failed to ensure Minimum Data Set (MDS) assessments were accurately coded for two residents reviewed during a complaint survey. For one resident, a facility-reported incident showed that the resident was found seated on the floor beside the bed and was diagnosed with a non-displaced femoral neck impaction fracture of the left hip following an x-ray. Despite this fall with a major injury, the subsequent significant change MDS dated 11/4/25 did not code the fall with major injury in Section J1900C. Review of the resident’s Medication Administration Records for October and November 2025 showed administration of Tylenol on 10/31/25 at 9:30 PM, which fell within the 5-day look-back period for the MDS, but Section J0100 (prn pain) of the same significant change MDS did not capture the use of Tylenol. For another resident, review of a quarterly MDS with an assessment reference date of 10/15/25 showed that Section N0415 (High-Risk Drug Classes) documented the use of an opioid medication. However, review of the resident’s October 2025 Medication Administration Record did not show that the resident had been prescribed an opioid during that period. In both cases, MDS staff later confirmed that these were errors in MDS coding, demonstrating that the assessments did not accurately reflect the residents’ clinical status and medication use as documented in their medical records.
Incomplete Documentation of Narcotic Administration on MAR
Penalty
Summary
The facility failed to maintain complete and accurate medical records in accordance with accepted professional standards for one resident receiving narcotic medication. The resident, admitted in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26. Review of the March 2026 Medication Administration Record (MAR) showed documentation of a single 25 mg dose of Tramadol administered on 3/8/26 at 9:23 AM. However, review of the resident’s Controlled Drug Receipt/Record/Disposition Form, kept on the nurse’s medication cart and not in the medical record, showed that Tramadol 25 mg was administered three times between 3/8/26 and 3/9/26: at 11:00 AM and 9:00 PM on 3/8/26, and at 9:00 AM on 3/9/26. In interview, the DON stated that staff are expected to document narcotic administration on the MAR and confirmed that only one of the three Tramadol doses reflected on the controlled drug record was documented on the resident’s MAR. This discrepancy between the controlled substance record and the MAR, with missing documentation of two administered doses of Tramadol on the official medical record, constituted the failure to maintain a complete and accurate medical record for the resident.
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What surveyors actually found near you
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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 Sandy Spring
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Friends Nursing Home | 1.2 mi | ★★★★★ | 15 | 0 |
| Bedford Court Healthcare Cent. | 4 mi | ★★★★★ | 25 | 0 |
| Layhill Nursing And Rehabilitation Center | 4.6 mi | ★★★★★ | 33 | 0 |
| Harmony Suites Rehabilitation And Wellness Center | 5.4 mi | ★★★★★ | 28 | 1 |
| Fairland Center | 6.6 mi | ★★★★★ | 5 | 0 |
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