Above average — CMS composite of the measures below.
The next survey window likely opens around April 2027
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 Brookefield Park during CMS and state inspections, most recent first.
Kitchen surface cleaning was not performed often enough to prevent soil buildup. Surveyors observed a cloudy yellow-white residue on the stainless-steel partition behind the stove and steamer, and the daily, weekly, and monthly cleaning schedules did not list that surface. The cook said Maintenance was responsible for cleaning it and was unsure of the frequency, while the MS confirmed the buildup and stated the wall was only wiped down about every 3 months.
Missing Medication Aide Competency Documentation: The DON confirmed that a medication aide had no documented competency assessments for oral or topical medication administration during orientation, and the only competency the facility could produce was for eye medication instillation. MARs showed the medication aide administered multiple oral, ophthalmic, and topical medications to several residents, while the facility’s own records stated that medication aide competencies were to be completed during orientation and maintained in the employee file.
Failure to Check Food Temperatures Before Serving: Dietary staff served hot and cold food items to multiple residents without checking temperatures first. A cook microwaved soup, steamed a hamburger and cheese curds, and plated salads, chicken nuggets, grapes, and cottage cheese for residents without verifying that the items were at safe and palatable temperatures. The DM confirmed that all items served from the kitchen should have their temperatures checked.
Incorrect MDS Coding for Insulin Administration: A resident's Quarterly MDS was coded to show insulin use in section N0350, but MAR review showed the resident received Ozempic, not insulin, during the look-back period. The MDSC confirmed there was no insulin administration documented and that the Ozempic injection had been incorrectly coded as insulin.
The facility failed to maintain refrigerated foods at the required temperatures, with observations showing consistent temperatures above 41°F in the walk-in refrigerator. Interviews revealed that staff did not properly record or address out-of-range temperatures, and there was a discrepancy in temperature standards between the Dietary Manager and Registered Dietitian. This deficiency potentially affected all 58 residents consuming food from the facility kitchen.
The facility did not ensure that three nursing aides completed the required 12 hours of annual training, with NA-H, NA-G, and NA-I completing only 6.82, 6.38, and 9.69 hours respectively. This deficiency was confirmed by the DNS and HR, potentially impacting all 58 residents, as staff competencies in mental health, dementia, and infectious diseases were necessary.
A facility failed to conduct a Level II PASRR for a resident newly diagnosed with a serious mental illness and prescribed an antipsychotic medication. Initially assessed with a Level I PASRR, the resident was later diagnosed with delusional disorder and prescribed Seroquel, but the required Level II evaluation was not completed. This was confirmed by the Social Services Director.
Kitchen Surface Cleaning Not Performed Frequently Enough
Penalty
Summary
The facility failed to ensure that kitchen surfaces were cleaned often enough to prevent the accumulation of soil or residue. During an observation of the kitchen, a cloudy yellow-white buildup was seen on the stainless-steel partition behind the stove and the facility steamer, extending in a downward V shape from about 5 inches below the top to about 3 feet from the bottom along the length of the partition. Record review of the facility’s daily, weekly, and monthly cleaning schedules for May 2026 showed no listing for the stainless-steel partition behind the stove and the facility steamer to be cleaned. In interview, the cook stated they believed Maintenance was responsible for cleaning the stainless-steel partition and were unsure how often it was cleaned. The Maintenance Supervisor confirmed the buildup was present and stated the stainless-steel wall was wiped down about every 3 months, which was not frequent enough to prevent the buildup from occurring.
Missing Medication Aide Competency Documentation
Penalty
Summary
The facility failed to ensure that medication aide competency assessments were documented and maintained for one medication aide reviewed. The facility assessment stated that staff competencies for medication administration would be assessed during orientation, annually, and as needed, and the facility competency list stated that medication administration competency for all routes approved by the facility would be completed for medication aides only. The medication aide in question had a hire date of 11/11/25 and began orientation on 11/11/25, but the employee file contained no medication aide competency assessments. The record showed that the medication aide completed floor orientation and multiple medication aide orientation entries, but the only competency assessment the facility could provide was for instilling medication into the eye dated 5/4/26. That checklist identified eye administration as observed, while ear and nose administration were not marked as observed. During interview, the DON confirmed that medication aides were allowed to administer medications by mouth, into the eye, into the nose, topically, and rectally, and confirmed that competency assessments for all routes were to be completed during orientation. The DON also confirmed that the facility had no medication aide competency assessments for oral or topical medication administration for this medication aide. Medication administration records showed the medication aide administered multiple medications to residents by mouth, including Tylenol, Levothyroxine, Zyprexa, Donepezil, Lexapro, Melatonin, Seroquel, Tramadol, Depakote, Hydroxyzine, Senna, Acetaminophen, Gabapentin, Lorazepam, Rexulti, Trazodone, Memantine, Propranolol, and Valsartan. The medication aide also administered ophthalmic medications such as Systane Complete, Latanoprost, Cyclosporine, and Artificial Tears, and topical medications including Vicks Baby Rub, Voltaren External Gel, and Vaseline External Gel. The DON confirmed at interview that the facility had no documentation of the required medication aide competency assessments from orientation for this medication aide.
Failure to Check Food Temperatures Before Serving
Penalty
Summary
The facility failed to check the temperature of food items served from the kitchen to ensure they were at a safe and palatable temperature for five sampled residents: Resident 4, Resident 17, Resident 55, Resident 7, and Resident 32. A facility policy titled Food Temperatures stated that temperatures of food items are to be taken and properly recorded for each meal, with hot foods held and served at 135 degrees Fahrenheit or above and cold foods maintained and served at 41 degrees Fahrenheit or below. During observation, Dietary staff member A prepared and served multiple items without checking temperatures. Tomato soup was heated in a microwave and handed off for service to Resident 4 without a temperature check. A hamburger and cheese curds were removed from packaging, steamed, and served to Resident 17 without temperature verification. Salad served to Resident 55 and salad topped with a hardboiled egg served to Resident 7 were taken from containers with ice but were not checked for temperature before being served. Chicken nuggets, grapes, and cottage cheese served to Resident 32 were also not temperature checked. The dietary staff member confirmed not checking the temperatures of the soup, hamburger, cheese curds, salads, chicken nuggets, and cottage cheese, and the Dietary Manager confirmed that all items served from the kitchen should have their temperatures checked for safety and palatability.
Incorrect MDS Coding for Insulin Administration
Penalty
Summary
The facility failed to accurately code the Minimum Data Set (MDS) for one resident in the sample. Record review showed the facility policy required accurate standardized assessment of each resident's functional capacity according to the MDS guidelines and RAI Manual. The RAI Manual instructions for N0350 require coding the number of days during the 7 days prior to the ARD that the resident received insulin injections. Resident 5's Quarterly MDS with an ARD of 02/18/2026 was coded as receiving insulin on 1 day in section N0350. However, review of the February 2026 MAR showed the resident had orders for Ozempic, which is not insulin, and there was no documentation that the resident received an insulin injection during the 7-day period before the ARD. In interview, the MDSC confirmed the resident did not receive insulin during that period, that the Ozempic injection had been coded as insulin, and that the MDS was coded incorrectly.
Refrigeration Temperature Control Deficiency
Penalty
Summary
The facility failed to maintain refrigerated foods at the required temperatures, which is essential for food safety. Observations in the facility's main kitchen revealed that the thermometer inside the walk-in refrigerator consistently displayed temperatures above the required 41 degrees Fahrenheit. Specifically, temperatures were recorded at 44 degrees Fahrenheit on multiple occasions, with milk and cottage cheese stored inside. These observations were made over several days, indicating a persistent issue with maintaining the correct temperature. Interviews with dietary staff and record reviews further highlighted the deficiency. The dietary staff member responsible for recording refrigerator temperatures confirmed that the temperatures were not being recorded as required each morning. Additionally, the staff member indicated that out-of-range temperatures should be circled on the temperature log, but this was not done. The temperature log for February 2025 showed that 26 out of 38 recorded temperatures were above the required 41 degrees Fahrenheit, yet none of these were circled to indicate they were out of range. The facility's Dietary Manager and Registered Dietitian were also interviewed, revealing discrepancies in the expected temperature standards. The Dietary Manager stated that the expected temperature for refrigerators was 45 degrees Fahrenheit or below, which contradicts the Registered Dietitian's confirmation that temperatures should be kept at 40 degrees Fahrenheit or below for food safety. This inconsistency in understanding and enforcing temperature standards contributed to the deficiency, as the facility failed to ensure that refrigerated foods were stored at safe temperatures, potentially affecting all 58 residents who consumed food prepared by the facility kitchen.
Deficiency in Nursing Aide Training Hours
Penalty
Summary
The facility failed to ensure that three out of five sampled nursing aides received the required 12 hours of ongoing training over the past 12 months, as mandated by licensure reference 175 NAC 12-006.04(B)(ii)(1). This deficiency was identified through record reviews and interviews. Specifically, NA-H completed only 6.82 hours, NA-G completed 6.38 hours, and NA-I completed 9.69 hours of training within the specified period. The Director of Nursing Services and Human Resources confirmed during an interview that these nursing aides did not meet the annual training requirements. This oversight had the potential to affect all 58 residents residing at the facility, as the facility's assessment indicated the need for staff to have competencies in areas such as mental health, dementia, and infectious diseases.
Failure to Complete Level II PASRR for Resident with New Mental Illness Diagnosis
Penalty
Summary
The facility failed to complete a Level II Pre-Admission Screening and Resident Review (PASRR) for a resident who was newly diagnosed with a serious mental illness and had a change in psychotropic medication. The deficiency involved Resident 10, who was initially assessed with a Level I PASRR on 05/02/2024, indicating no serious mental illness and routine use of antidepressant and opioid medications. However, on 05/09/2024, Resident 10 was diagnosed with delusional disorder, a serious mental health condition, and later prescribed Seroquel, an antipsychotic medication, on 11/14/2024. Despite these significant changes in Resident 10's mental health status and medication regimen, the facility did not conduct a Level II PASRR evaluation as required. This oversight was confirmed during an interview with the facility's Social Services Director, who acknowledged the absence of a Level II PASRR reflecting the resident's new diagnosis and medication use. The facility census at the time was 58, and Resident 10 was the only sampled resident affected by this deficiency.
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Illustrative
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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Illustrative
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Nursing homes near St Paul
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Good Samaritan Society - Grand Island Village | 20.9 mi | ★★★★★ | 16 | 0 |
| Tiffany Square | 21 mi | ★★★★★ | 7 | 0 |
| Adept Nursing & Rehab Of Grand Island | 21.1 mi | ★★★★★ | 0 | 0 |
| Chi Health St. Francis | 21.2 mi | ★★★★★ | 0 | 0 |
| Eventide Prairie Commons Care Center | 23.5 mi | ★★★★★ | 0 | 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.