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 Brookestone Acres during CMS and state inspections, most recent first.
The facility did not complete or document required care plan conferences for three residents, including those with Multiple Sclerosis and varying cognitive statuses. Residents reported not being involved in care planning, and staff confirmed that care conferences were delayed or missing, with no consistent scheduling or notification process in place.
Two residents requiring CPAP therapy for conditions such as sleep apnea and respiratory failure had physician orders that lacked specific settings, including pressure, ramp time, and humidity. The DON confirmed that the orders were incomplete and that staff could not identify the intended settings, despite facility policy requiring verification of such details before initiating CPAP therapy.
The facility did not ensure that the posted Daily Nurse Staffing Form accurately reflected the actual census, as the form consistently displayed a higher number than the true census confirmed by administrative staff. Staff interviews revealed a lack of policy and procedure for completing the form, and the form was not updated daily as required.
The facility failed to implement and revise fall prevention interventions for two residents, leading to multiple falls. One resident, with dementia and hemiplegia, was not consistently toileted or supervised as per their care plan, resulting in numerous falls. Another resident, cognitively impaired, experienced falls without new interventions being developed. Staff did not adhere to established fall prevention measures, contributing to the ongoing risk of falls.
A facility failed to document a diagnosis and attempt a gradual dose reduction (GDR) for psychotropic medications prescribed to a resident with Alzheimer's, dementia, anxiety, and depression. Despite recommendations from the Consultant Pharmacist, the physician continued the use of Lorazepam and Seroquel without providing a clinical rationale for not attempting a GDR. The Director of Nursing confirmed the lack of evidence for GDR attempts or documented contraindications.
Failure to Complete and Document Timely Care Plan Conferences
Penalty
Summary
The facility failed to complete and document comprehensive care plans and conduct interdisciplinary care conferences for three sampled residents, as required by regulatory guidelines. Record reviews for these residents showed an absence of care plan meeting notes, care conference summaries, or care plan acknowledgment forms over the past six months. Interviews with residents confirmed that they had not participated in care plan conferences for an extended period, and staff interviews corroborated that care conferences were behind schedule and not consistently documented. For one resident, the Minimum Data Set (MDS) assessment indicated a moderate cognitive impairment and a primary diagnosis of Multiple Sclerosis, yet there was no evidence of care plan meetings or documentation. Another resident, also with Multiple Sclerosis and a high cognitive function score, similarly lacked documentation of care plan conferences. A third resident, who was cognitively intact, had some care plan meetings documented, but there were missing records for required quarterly and annual conferences, and the resident reported no involvement or awareness of such meetings. Staff interviews revealed that there was no current system for scheduling care plan conferences, and notifications to families were not consistently sent in a timely manner. The facility's electronic health record system was intended to trigger the care plan process, but this was not reliably followed. Additionally, there was no facility policy on care planning, and the social services staff did not have a process for tracking care conferences, contributing to the ongoing deficiency.
Incomplete Physician Orders for CPAP Therapy
Penalty
Summary
The facility failed to ensure that physician orders for CPAP (Continuous Positive Airway Pressure) therapy included complete and specific settings for two residents. For both residents, the care plans indicated the use of CPAP as an intervention for conditions such as chronic respiratory failure with hypoxia, obstructive sleep apnea, and ALS. However, a review of the clinical physician orders revealed that the orders lacked essential details such as pressure, ramp time, and humidity settings. In one case, the order simply stated 'CPAP when sleeping - every night shift' without specifying any settings, and in another, the order referenced 'current settings' or 'per home settings' without documentation of what those settings were. The facility's policy required verification of the practitioner's order, including all necessary settings, before initiating CPAP therapy. During interviews, the DON confirmed that the physician orders for both residents did not include the required specifications and acknowledged that staff could not identify or interpret 'per home settings.' The lack of complete and specific physician orders for CPAP therapy was observed for both residents, despite their documented need for this respiratory intervention.
Inaccurate Posting of Daily Nurse Staffing Census
Penalty
Summary
The facility failed to ensure that the posted Daily Nurse Staffing Form accurately reflected the actual facility census. Observations on multiple days revealed that the posted census was consistently listed as 78, while interviews with the Administrator and Assistant Director of Nursing confirmed the actual census was 74 or 75 on those days. The Staffing Coordinator acknowledged that the form should display the actual daily census and noted that the forms are printed on Mondays for the past weekend. Additionally, the Regional Nurse Consultant stated there was no facility policy or procedure for completing the Daily Nurse Staffing Form, and the Administrator confirmed the inaccuracy of the posted census information. The Administrator also stated that the form should be printed and posted before the day and updated as needed.
Failure to Implement Fall Prevention Interventions
Penalty
Summary
The facility failed to implement, revise, and develop new interventions to prevent further falls for two residents, identified as Residents 14 and 41, out of a sample of four. Resident 41, who was admitted with diagnoses of dementia, hemiplegia, and depression, was totally dependent on staff for assistance with mobility and had a history of multiple falls. Despite having a care plan with various interventions to prevent falls, the facility did not consistently implement these measures. Observations revealed that staff failed to toilet the resident before and after meals, did not place the resident in the commons area for visual supervision, and did not adhere to the walk-to-dine program, which were all part of the resident's fall prevention plan. The facility's Fall Scene Investigation Reports for Resident 41 documented numerous falls, each with identified interventions that were not consistently followed. For instance, the resident was not toileted frequently enough, and staff did not ensure the resident was assisted to the bathroom immediately after meals. Additionally, the resident was not placed in a regular chair in the dining room as required, and staff failed to provide the necessary supervision to prevent self-transfers, which led to multiple falls. Similarly, Resident 14, who was cognitively impaired and dependent on staff for assistance, experienced falls without new interventions being implemented. The resident's care plan included measures such as placing frequently used items within reach and ensuring the resident was toileted before and after meals. However, the facility did not develop new interventions following falls on specific dates, as confirmed by interviews with the Director of Nursing and the Administrator. This lack of action contributed to the ongoing risk of falls for Resident 14.
Failure to Document Diagnosis and Attempt GDR for Psychotropic Medications
Penalty
Summary
The facility failed to have a diagnosis for the use of an antipsychotic medication and did not attempt a gradual dose reduction (GDR) or document a contraindication for the use of the antipsychotic medication for one resident. The facility's policy required that psychotropic drugs be given only when necessary to treat a specific condition, with the indication for use documented in the medical record. The policy also required that residents using psychotropic medications receive GDRs unless clinically contraindicated. However, the facility did not adhere to these guidelines for Resident 50, who was prescribed Lorazepam and Seroquel without proper documentation or attempts at GDR. Resident 50 had diagnoses of Alzheimer's disease, dementia, anxiety, and depression, and was taking both an antipsychotic and an antianxiety medication. The Consultant Pharmacist recommended a GDR for Lorazepam, but the physician continued the medication without providing a clinical rationale. Similarly, for Seroquel, the physician provided a new diagnosis of agitation/dementia but did not document a clinical rationale for not attempting a GDR. The Director of Nursing confirmed that there was no evidence of attempts at GDR or documented contraindications for the continued use of these medications.
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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 Columbus
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Emerald Nursing & Rehab Columbus | 0.7 mi | ★★★★★ | 30 | 0 |
| Genoa Community Hospital/ltc | 18 mi | ★★★★★ | 0 | 0 |
| St. Joseph's Villa, Inc. | 19 mi | ★★★★★ | 20 | 0 |
| Brookestone Of David City | 19.7 mi | ★★★★★ | 0 | 0 |
| Good Samaritan Society - Osceola | 20.5 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.