Above average — CMS composite of the measures below.
The next survey window likely opens around January 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 Brookestone Village during CMS and state inspections, most recent first.
A resident with advanced dementia and severe cognitive impairment, whose legal representative had been designated to make care decisions, alleged inappropriate touching by a male NA following perineal care. After this allegation, the representative and facility agreed that the resident would have female-only caregivers, and this requirement was documented in the care plan and physician orders. Despite this, staffing records and staff interviews show that male NAs and an RN continued to be the only caregivers scheduled on the resident’s unit on multiple shifts and did provide care, failing to honor the representative’s directive for female-only caregivers.
Infection control practices were not followed during a Norovirus outbreak in a resident room on Droplet/Contact Precautions. An MA entered one isolation room with goggles, then went to another room without disinfecting the eyewear, and stated they did not think cleaning was needed between residents. In a separate event, an NA entered an isolation room without a face shield while carrying a tray of individually wrapped donuts; the ADON confirmed the tray should not have been brought into the room and that this was a breach of isolation procedure.
Failure to report and investigate an allegation of abuse: A cognitively intact resident with rhabdomyolysis and anxiety reported that an NA removed ace wraps roughly and hurt the resident. The resident told an MA and an LPN, but the facility did not suspend the NA, did not open an abuse investigation right away, and did not report the allegation to APS or DHHS until later.
A resident with moderate cognitive impairment and diagnoses including dementia, frontal lobe/executive function deficit, depression, and anxiety was repeatedly identified as high elopement risk, but the care plan did not include an elopement risk focus or any interventions. Staff confirmed the resident was on the elopement list, an alarm was attached to the room door, and the ADON acknowledged the care plan update had not been completed.
Failure to Implement Pressure Injury Prevention: A resident with a hip fx, PVD, lymphedema, foot drop, limited mobility, and a Braden score indicating pressure injury risk developed a left heel pressure injury after the facility did not have pressure-reducing interventions in place. Records showed no turning/repositioning task or skin-related care plan interventions until after the heel blister was found, and staff later observed the resident seated with both heels resting on wheelchair footrests.
The facility failed to maintain complete respiratory orders for two residents on oxygen and one resident using a PAP device. One resident’s oxygen order lacked a dose and route, another resident’s oxygen order lacked a dose, and a third resident had documented PAP use in progress notes and at bedside but no physician order. Staff and the ADON confirmed the missing order details, while observations showed the residents using oxygen at 2 L/min and the PAP machine in the room.
The facility failed to update CCPs for residents, leading to deficiencies in wound care, medication management, and behavior interventions. A resident's skin tear was not included in the care plan, another's pressure injury lacked updated interventions, and a third's new medication was not reflected in their care plan. Additionally, a resident's behavior interventions were outdated, highlighting a failure to maintain current care plans as per facility policy.
Failure to Honor Resident Representative’s Female-Only Caregiver Directive After Abuse Allegation
Penalty
Summary
The deficiency involves the facility’s failure to honor a resident representative’s directive that the resident receive care only from female caregivers following an allegation of sexual abuse. Facility resident rights documents dated 05/19 state that residents have the right to designate a legal representative to make choices about care and significant aspects of life in the facility, including health care and health providers. The resident’s admission agreement and responsible party acknowledgment dated 12/12/2025 identify a family member as the resident’s responsible party/legal representative, authorized to handle certain matters on the resident’s behalf, and the resident was provided with the facility’s resident rights. The resident was admitted on 12/12/2025 and had diagnoses including Major Depressive Disorder, cognitive communication deficit, and previously undocumented dementia. A PASARR Level I screen documented advanced, primary, or late-stage dementia or neurocognitive disorder. The MDS dated 03/04/2026 showed a BIMS score of 7/15, indicating severe cognitive impairment, with the resident requiring substantial/maximal assistance for mobility, transfers, upper body dressing, and being dependent for toileting hygiene, lower body dressing, and footwear. The resident required supervision or touching assistance for personal hygiene and was independent only with eating. On 03/13/2026, progress notes document that a NA provided perineal care, after which the resident began screaming and crying. Staff entered the room and the resident reported that a man had come into the room and inappropriately touched and groped the resident. Staff contacted the resident’s representative the same day, and they agreed the resident would have female-only caregivers. The care plan and clinical physician orders were updated to include an intervention and special instructions for “FEMALE ONLY CAREGIVERS.” However, staffing assignment records from 02/25/2026–03/29/2026 show that male staff (NA-B, NA-C, and RN-A) were the only caregivers scheduled on multiple shifts on the resident’s unit after this directive, and interviews confirm that the male NA involved in the allegation and a male RN continued to provide care to the resident despite the documented female-only caregiver requirement and the representative’s stated preference.
Infection Control Breaches During Norovirus Isolation
Penalty
Summary
The facility failed to ensure infection prevention and control practices were followed during a Norovirus outbreak in a resident room placed on Droplet/Contact Precautions. Survey observations on 02/19/2026 showed Medication Aide J entered the isolation room wearing a mask, gloves, gown, and goggles, then exited and went to another resident room with the goggles still on top of the head without disinfecting them. In interview, Medication Aide J stated they did not think the goggles needed to be cleaned or disinfected between residents, and the ADON confirmed the eyewear was expected to be cleaned and disinfected between residents. The facility also failed to restrict communal food items from entering an isolation room. During another observation on 02/19/2026, Nursing Assistant K entered a Droplet/Contact Precautions room carrying a plastic tray and later exited with a tray containing 7 plates of individually wrapped single donuts. Nursing Assistant K stated they forgot to put on a face shield and did not know whether bringing the tray of donuts into the room was a breach of isolation procedure. The ADON confirmed the NA should have worn a face shield and that the tray of donuts should not have been taken into the isolation room, identifying this as a breach of Droplet/Contact isolation.
Failure to Report and Investigate Allegation of Abuse
Penalty
Summary
The facility failed to report and investigate an allegation of abuse involving Resident 22 within the required timeframe. Resident 22 was admitted with a diagnosis of rhabdomyolysis and had an MDS showing a BIMS score of 14, indicating the resident was cognitively intact. The resident also had a diagnosis of anxiety disorder and required assistance with footwear. The facility’s Abuse and Neglect Prevention Standard required all allegations of abuse to be reported immediately, but no later than 2 hours, and required immediate notification of the Administrator, DON, and Social Services, along with immediate suspension of the suspected team member while an investigation was conducted. Resident 22 reported that on 2/17/2026 at about 8:00 PM, NA G removed ace wraps roughly from the resident’s legs and hurt the resident. Resident 22 told MA D later that evening and also spoke with LPN H about the incident. MA D confirmed the resident said NA G was rough and hurt the resident’s legs, and that the resident did not want NA G to provide care again. ADON B confirmed the facility had not suspended NA G, had not opened an abuse investigation, and had not reported the incident to APS or DHHS. The DON confirmed LPN H called at midnight on 2/17/26 and reported that Resident 22 said NA G hurt them when removing the ace wraps, but the facility did not open an abuse investigation until the afternoon of 2/18/2026.
Care Plan Missing Elopement Risk Focus and Interventions
Penalty
Summary
The facility failed to ensure the complete care plan was developed within 7 days of the comprehensive assessment and prepared, reviewed, and revised by a team of health professionals for a resident identified as a high elopement risk. Record review showed the resident had an undated care plan that did not include a Risk for Elopement focus and did not contain any elopement interventions, despite repeated elopement risk assessments identifying the resident as high risk on multiple occasions. The resident’s clinical profile showed admission to the facility and a CMS-accepted MDS with a BIMS score of 10, indicating moderate cognitive impairment. The resident’s diagnoses included frontal lobe and executive function deficit following cerebral infarction, unspecified dementia with mood disturbance, major depressive disorder, and generalized anxiety disorder. The resident’s elopement risk assessments repeatedly identified the resident as high risk, and the Elopement Risk Manual contained the resident’s picture and description details. During observation, an electronic alarm was attached to the top exterior of the resident’s room door. Staff interviews confirmed the resident was on the elopement list, that the facility maintained an elopement risk manual and list accessible to staff, and that nursing was responsible for completing the elopement risk assessment while the ADON was responsible for updating the care plan. The ADON confirmed the resident’s care plan did not contain a risk for elopement or interventions and that the care plan update had not been completed.
Failure to Implement Pressure Injury Prevention
Penalty
Summary
The facility failed to implement pressure injury prevention interventions for a resident who was admitted with multiple risk factors, including a right hip fracture, peripheral vascular disease, lymphedema, and left foot drop. The resident’s admission MDS showed moderate cognitive impairment, dependence for many transfers and mobility tasks, and existing skin issues including a stage I pressure ulcer, an unstageable pressure injury, and a surgical wound. The Braden Scale on 01/22/2026 scored the resident at 17, indicating risk for pressure injury, and the resident was chairfast with very limited mobility and friction/shear concerns. Although the resident’s skin was initially documented as without major concerns aside from edema, the record did not show turning/repositioning tasks or other pressure-reducing interventions until the left heel wound was identified. Nursing documentation later described a large fluid-filled blister on the left heel measuring 3 cm by 2.8 cm, dark red and purple in color, and the resident was instructed not to wear shoes and to use gripper socks and Prevalon boots in bed. The pressure ulcer record identified the heel wound as an unstageable pressure ulcer, and the incident report noted predisposing factors including gait imbalance, footwear type, a history of left foot drop, and an extended period lying on the floor after a fall before EMS arrived. Record review showed the care plan did not include a focus area or interventions for potential skin impairment until after the heel wound was found, and the task list did not show pressure injury prevention interventions until that same time. The facility’s air mattress order was not completed until the day after it was placed. During later observations, the resident was seen sitting in a wheelchair with both heels directly on the footrests, and wound care documentation showed the left heel remained an intact partially fluid-filled purple blister. Staff interviews confirmed there were no pressure-reducing interventions in place before the heel wound was discovered, and the ADON acknowledged the resident had been at risk based on the Braden Scale but did not have pressure-reducing interventions in place before the wound developed.
Incomplete Oxygen Orders and Missing PAP Device Order
Penalty
Summary
The facility failed to ensure respiratory orders were complete for two residents receiving oxygen and failed to ensure one resident had a documented order for a PAP device. The deficiency was identified through observation, interview, and record review involving Residents 144, 147, and 160, with the facility census listed as 122. Resident 144’s order summary showed only an order to titrate oxygen to maintain an oxygen level of 90% two times a day for safe mobility, but the order did not include a dose or route. The MAR and TAR showed the oxygen order was marked two times a day except for two shifts. Observations showed the resident using a nasal cannula with the concentrator set at 2 L/min on 02/18/2026 and 02/23/2026, and on 02/23/2026 the resident was observed on an exercise bike without oxygen, with an oxygen saturation of 82%; therapy staff then obtained the oxygen tank and placed the resident on oxygen at 2 L/min, increasing saturation to 95%. Resident 144 stated the resident had been on oxygen at 2 L/min since admission, and the ADON confirmed the only oxygen order did not contain a setting. Resident 147’s order summary listed oxygen via nasal cannula two times a day, but the order did not include a dose. The MAR and TAR showed the oxygen via nasal cannula was marked administered two times a day except for two shifts. Observations showed the resident with a nasal cannula in place and the concentrator set at 2 L/min on 02/18/2026 and 02/19/2026. For Resident 160, the clinical physician orders did not include an order for the PAP device, although progress notes documented use of a PAP machine on multiple dates, the device was observed at the bedside, and the resident stated the PAP machine was brought to the facility on admission and used every night. The ADON confirmed the resident had a PAP device, did not have an order for it, and should have.
Failure to Update Comprehensive Care Plans
Penalty
Summary
The facility failed to update the Comprehensive Care Plans (CCP) for several residents, leading to deficiencies in wound care, medication management, and behavior interventions. Resident 88, who was at risk for developing wounds, had a skin tear on the left lower leg that was not included in the care plan despite being identified and treated. The facility's policy required that all actions and interventions be included in the care plan at the time of identification, but this was not adhered to, as confirmed by interviews with the RN and ADON. Resident 7 had a new pressure area on the right second toe, which was identified during a weekly visual skin check. However, the care plan was not updated with new interventions or revisions after the discovery of the pressure injury, contrary to the facility's Skin and Wound Management policy. This oversight was confirmed by the ADON, who acknowledged that the care plan should have been updated to reflect the new condition. Resident 87 was prescribed Ativan for anxiety, but the care plan was not revised to include this new medication and its management. Similarly, Resident 69's care plan did not reflect specific behaviors and interventions related to their dementia-related diagnosis, despite documented behaviors and staff interventions. The care plan had not been updated since 2019, and the lack of personalized interventions was confirmed by the ADON. These deficiencies highlight a failure to maintain current and comprehensive care plans as required by the facility's policies.
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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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| Hillcrest Millard Llc | 1.1 mi | ★★★★★ | 10 | 0 |
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| The Banyan At Montclair | 1.5 mi | — | 19 | 0 |
| Rose Blumkin Jewish Home | 2.9 mi | ★★★★★ | 7 | 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.