Above average — CMS composite of the measures below.
The next survey window likely opens around May 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 Brookestone Of David City during CMS and state inspections, most recent first.
Medication carts on the 200 and 300 halls were observed unlocked with no staff nearby, despite the facility policy requiring all medication storage areas and carts to be locked. RN, MA, LPN, and the ADON all confirmed the carts should have been locked when not in use.
A resident who was dependent on staff for toileting hygiene and transfers, and who had intact cognition, reported that staff did not provide privacy during care and that other residents and families were often visible nearby. Observations showed the resident’s shade remained up while NAs assisted the resident to and from the bathroom with a sit-to-stand lift, and an RN and the ADON confirmed privacy should have been provided.
The facility failed to complete significant change MDSs for two residents after major status changes were identified. One resident had a stroke history, DM, CKD, weight loss, and a new Stage 3 coccyx pressure ulcer, and the ADON confirmed a significant change MDS was needed. Another resident was admitted on hospice, later discontinued hospice, and records plus staff interviews confirmed no significant change MDS was completed when hospice services ended.
The facility did not accurately document the use of hypoglycemic medications in the MDS for two residents. One resident received Metformin, and another received multiple insulin medications during their respective observation periods, but these were not reflected in their MDS. The ADON/MDS Coordinator confirmed the oversight.
The facility failed to follow its bowel protocol for two residents, resulting in prolonged periods without bowel movements. One resident did not receive appropriate interventions or medical provider notifications despite multiple days without a bowel movement. Another resident experienced a similar lapse, with no medications administered or documentation of bowel assessments. The Assistant Director of Nursing confirmed these deficiencies.
The facility failed to ensure proper hand hygiene and infection control during care for two residents. One resident, with a recent UTI, did not receive appropriate hand hygiene from nursing assistants during incontinence care. Another resident, with a stage 2 pressure ulcer, experienced improper glove use and hand hygiene during peri-care and wound care. These deficiencies were confirmed by the ADON/MDS Coordinator and the Infection Preventionist.
Unlocked Medication Carts on 200 and 300 Halls
Penalty
Summary
The facility failed to ensure medications were securely stored on the 200 and 300 hallways. The facility’s Medication Storage and Utilization policy, last reviewed in 03/19, stated that all medication storage areas, rooms, and carts must be locked. During an observation on 06/01/2026 at 10:05 AM, the 300-hall medication cart was observed unlocked with no staff near it, while staff walked past the cart. RN-B later confirmed that the cart should have been locked and was not. Additional observations on 06/02/2026 showed the same issue on the 200 hall. From 9:05 AM to 9:08 AM, the medication cart was observed unlocked with no staff nearby, and MA-D then locked the cart. MA-D confirmed the cart should have been locked. From 11:05 AM to 11:07 AM, the 200-hall medication cart was again observed unlocked with no staff near it, and LPN-C confirmed it should have been locked. The ADON later confirmed that all medication carts were expected to remain locked when staff were not using them.
Failure to Provide Privacy During Personal Care
Penalty
Summary
The facility failed to provide privacy during personal care for one resident who was dependent on staff for toileting hygiene and transfers and required assistance from two staff members with a mechanical lift. The resident’s MDS showed a BIMS score of 15/15, and the resident stated that staff do not provide privacy when performing cares and that other residents and families were often walking or sitting in the gazebo. During observations, the resident’s window shade was up while the resident could see other residents walking around the gazebo. Staff assisted the resident to and from the bathroom using a sit-to-stand lift without first pulling down the shade. RN-A was present during one of the observations and saw NAs assisting the resident. NA-E confirmed that the shade should have been pulled down, RN-A confirmed staff should have provided privacy, and the ADON stated it was the facility expectation to provide privacy during resident care.
Failure to Complete Significant Change MDSs for Two Residents
Penalty
Summary
The facility failed to complete a Significant Change MDS within 14 days after determining that a significant change had occurred for two residents. One resident had diagnoses including hemiplegia and hemiparesis following a cerebral infarction, Type 2 diabetes mellitus, chronic kidney disease, urinary retention, and depression. The resident’s admission MDS showed risk for pressure ulcers with no wounds present, but later record review documented an 11.9-pound, 6.6% weight loss over a short period and the development of a coccyx pressure ulcer that later deteriorated. The ADON, who was also the MDS coordinator, confirmed the resident had sustained significant weight loss and developed a Stage 3 pressure ulcer, and confirmed that a significant change MDS should have been completed. For the second resident, records showed the resident was admitted on hospice services and later was no longer receiving hospice. The hospice plan of care update indicated the resident had been discharged from hospice, and the quarterly MDS showed the resident was not receiving hospice services. Facility records and interviews confirmed there was no evidence that a significant change MDS was completed between admission and the quarterly assessment. The facility’s MDS completion policy stated that a significant change assessment is required when a resident receiving hospice services discontinues those services and remains in the facility, and both the LES and ADON confirmed that the significant change MDS should have been completed when hospice services ended.
Inaccurate MDS Documentation for Hypoglycemic Medication Use
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS), a comprehensive assessment tool used to develop a resident's plan of care, accurately reflected the use of hypoglycemic medications for two residents. Resident 23 was administered Metformin, a hypoglycemic medication, twice daily during a specified 7-day observation period. However, the MDS for Resident 23 did not indicate that hypoglycemic medication was taken during this period. This oversight was confirmed by the Assistant Director of Nursing/MDS Coordinator during an interview. Similarly, Resident 28 received multiple hypoglycemic medications, including Humalog and Insulin Detemir, during a different 7-day observation period. Despite this, the MDS for Resident 28 also failed to reflect the administration of these medications. The Assistant Director of Nursing/MDS Coordinator acknowledged that the MDS should have documented the use of hypoglycemic medications for both residents, indicating a lapse in accurately completing the MDS as per the guidelines outlined in the RAI Manual.
Failure to Follow Bowel Protocol for Two Residents
Penalty
Summary
The facility failed to adhere to its bowel protocol for two residents, leading to prolonged periods without bowel movements. Resident 23 did not have a bowel movement on multiple occasions, specifically from 1/15 to 1/18, 1/26 to 2/1, and 2/3 to 2/8. Despite having orders for Milk of Magnesia and Dulcolax suppositories to promote bowel movements, the facility did not follow the protocol, which required escalating interventions and notifying the medical provider by the fourth day without a bowel movement. The Assistant Director of Nursing confirmed that the protocol was not followed during these periods. Resident 35 also experienced a lapse in care regarding bowel management. The resident did not have a bowel movement from 1/22 to 1/26, and no medications were administered to prevent constipation during December, January, or February. The facility's bowel protocol was not followed, and there was no documentation of bowel assessments or notifications to the medical provider. The Assistant Director of Nursing confirmed the absence of bowel management in the resident's care plan and the lack of documentation in the Medication Administration Record.
Inadequate Hand Hygiene and Infection Control Practices
Penalty
Summary
The facility failed to ensure proper hand hygiene and infection control practices during the care of two residents, leading to potential cross-contamination. For Resident 19, who was dependent on staff for toilet hygiene and had a recent urinary tract infection, the nursing assistants did not perform hand hygiene or use gloves appropriately during incontinence care. Specifically, one nursing assistant touched the resident's facial hair without washing hands, and both assistants failed to change gloves or wash hands at critical points during the care process, such as after removing a saturated brief and before applying a new one. In the case of Resident 15, who had a stage 2 pressure ulcer and was always incontinent of bladder, the nursing assistant and LPN did not adhere to hand hygiene protocols during peri-care and wound care. The nursing assistant removed a brief and wiped the resident's buttocks without changing gloves or washing hands. Additionally, the assistant wiped across the resident's open wound after cleaning the rectal area, which could lead to contamination. The LPN also failed to perform hand hygiene when changing gloves during the procedure. These observations were confirmed by the Assistant Director of Nursing/MDS Coordinator and the Infection Preventionist, who noted the lack of hand hygiene and improper glove use. The deficiencies in hand hygiene and infection control practices were evident in both cases, highlighting a failure to follow established protocols designed to prevent cross-contamination and protect residents' health.
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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 David City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| St. Joseph's Villa, Inc. | 0.8 mi | ★★★★★ | 0 | 0 |
| Emerald Nursing & Rehab Columbus | 19 mi | ★★★★★ | 4 | 0 |
| Brookestone Acres | 19.7 mi | ★★★★★ | 0 | 0 |
| Ridgewood Rehabilitation & Care Center | 22.5 mi | ★★★★★ | 16 | 0 |
| Good Samaritan Society - Osceola | 22.7 mi | ★★★★★ | 4 | 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 October 2026) and official state health department websites.