Below average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
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 Brookview Healthcare Center during CMS and state inspections, most recent first.
A resident with multiple comorbidities and intact cognition sustained an unwitnessed fall in a dark room, was found on the floor with facial bleeding, a large forehead hematoma, periorbital bruising, and a lip laceration, and received Tylenol and wound cleansing from an LPN, but the physician was not contacted and EMS was not called until about two hours after the fall despite significant visible injuries and reported severe pain. In a separate incident, another cognitively intact resident with leg skin issues developed right knee skin tears after a fall, and although a physician ordered daily cleansing and dressing with non-adherent wrap, observation and resident report showed the knee dressing had not been changed the previous day, indicating the daily wound care order was not followed.
A resident with severe cognitive impairment and multiple chronic conditions, including Alzheimer’s disease, diabetes with polyneuropathy, psychotic disorder, hypertension, and severe protein-calorie malnutrition, had physician orders for Preservision AREDS, Protonix, and Refresh Tears. During a medication pass, an LPN did not administer these medications because they were unavailable, which was confirmed by MAR review showing they were not given as ordered. With 28 opportunities for medication administration and three omissions, the facility’s medication error rate was 10.7%, exceeding the 5% threshold, contrary to the facility’s medication administration policy.
The facility failed to prevent significant medication errors for two residents. A resident with documented allergies to Trazodone and Meloxicam, clearly noted in her pre-admission history and care plan, was nonetheless prescribed and administered Trazodone for insomnia and anxiety on multiple occasions before the allergy was recognized and the drug discontinued. Another resident with dementia and multiple comorbidities, ordered to receive a daily Rivastigmine 24-hour transdermal patch with instructions to remove the old patch before applying a new one, was observed with two patches in place from consecutive days, and an LPN reported having already removed an additional patch earlier, indicating three patches had been on simultaneously. These events occurred despite manufacturer instructions and facility policy requiring adherence to ordered dosages and proper patch removal.
A resident in an LTC facility experienced harm due to the facility's failure to provide timely treatment for constipation. Despite having physician orders for various constipation treatments, the resident did not receive any as-needed interventions for seven days, resulting in hospitalization for abdominal pain and stool impaction. The facility's bowel elimination policy was not followed, leading to the resident's condition worsening.
Two residents in the facility experienced significant weight loss without receiving adequate nutritional interventions. One resident, with dehydration and malnutrition, did not consistently receive prescribed supplements with meals. Another resident with dementia and dysphagia experienced weight loss without timely dietary adjustments, and double portions were not provided as ordered. The facility's policy for reweighing residents with significant weight changes was not consistently followed.
The facility failed to adequately monitor and document dialysis care for two residents requiring hemodialysis. One resident had multiple missed pre and post-dialysis evaluations, and another had no proper documentation or orders for a newly created fistula. Despite facility policies requiring regular assessments and documentation, these were not consistently followed, leading to deficiencies in care.
Two residents in an LTC facility did not receive prescribed medications due to pharmacy delivery issues and lack of communication. One resident missed doses of Lactulose for hyperammonemia, while another did not receive Tenapanor for irritable bowel syndrome. Both residents were aware of the missed medications, highlighting a failure in the facility's pharmaceutical services.
The facility failed to ensure timely responses to pharmacy recommendations for psychotropic medications, affecting three residents. A resident's medication evaluations were not addressed by a physician, and two residents experienced delays in implementing pharmacy recommendations for lab tests and dose reductions. The DON confirmed these failures.
A resident with type 2 diabetes did not receive insulin as ordered, leading to significant medication errors. Scheduled Humalog doses were administered late, and Tresiba doses were not given after the initial administration due to a pharmacy error. The LPN and DON confirmed these discrepancies.
An LPN failed to wear gloves while administering insulin to three residents and did not disinfect a glucometer between uses on two residents. Additionally, the DON did not follow contact precautions or perform hand hygiene when entering a resident's room with an infection, and subsequently entered another resident's room without proper hygiene measures.
Delayed Post-Fall Medical Response and Missed Wound Dressing Change
Penalty
Summary
The deficiency involves the facility’s failure to provide timely medical follow-up after a fall with injury and to complete wound care as ordered. One resident with multiple diagnoses including ovarian and abdominal lining cancer, dementia, gait difficulty, and osteoarthritis experienced an unwitnessed fall in her room in the early morning hours. A CNA discovered the resident on the floor around 4:45 A.M. in a dark room, with blood on her face and two pools of blood on the floor, after tripping over the resident’s wheelchair. An LPN cleaned the resident’s facial wounds, assessed her, and administered 650 mg of Tylenol for facial pain at 4:51 A.M., with the effectiveness documented as unknown. Despite the resident having a large hematoma on her forehead, bruising under both eyes, and a laceration to her upper lip exposing her teeth, the physician was not contacted until approximately 6:45 A.M., about two hours after the fall. The physician then ordered transfer to the emergency room, and EMS was called around 7:00 A.M., with the resident arriving at the emergency room at 7:23 A.M. EMS documentation noted that facility staff reported the fall had occurred approximately two hours before the 911 call, and the resident reported a pain score of nine out of ten upon arrival at the destination. The delay in notifying the physician and arranging emergency transport occurred even though the resident had significant visible injuries and ongoing pain. A second deficiency involved failure to follow physician orders for wound dressing changes. Another resident, cognitively intact and requiring partial/moderate assistance for personal hygiene, had scattered scabbing on both legs and developed two skin tears on the right knee after a fall. The physician ordered the right knee skin tears to be cleansed with normal saline, patted dry, covered with a non-adherent dressing, and wrapped daily and as needed until healed. On observation of wound care several days later, the dressing on the right knee was dated two days prior, and the wound nurse practitioner and the resident both confirmed that the dressing had not been changed the previous day. Review of the Treatment Administration Record showed documentation consistent with the earlier dressing date, indicating the daily dressing change order had not been carried out as written.
Medication Omission Leads to Elevated Medication Error Rate
Penalty
Summary
The deficiency involves the facility’s failure to ensure that all physician-ordered medications were administered to a resident, resulting in a medication error rate above 5 percent. Resident #70, admitted on 04/08/16, had multiple diagnoses including Alzheimer’s disease, diabetes mellitus with diabetic polyneuropathy, psychotic disorder with delusions, hypertension, severe protein calorie malnutrition, and muscle weakness. A quarterly MDS dated 01/29/26 documented severely impaired cognition with a BIMS score of 03. The resident’s care plan, dated 02/17/26, identified risk for alteration in mood related to anxiety, dementia, and depression, with an intervention to administer medications as ordered. Physician orders included Preservision AREDS 2 mg daily for macular degeneration, Protonix 40 mg daily for GERD, and Refresh Tears eye drops four times daily for dry eyes. On 02/23/26 at 9:05 A.M., an observation of LPN #362 preparing medications for Resident #70 showed that the LPN did not administer Preservision AREDS, Protonix, or Refresh Tears because the medications were unavailable. Concurrent interview with the LPN confirmed these medications would not be given at that time due to unavailability. Review of the February MAR showed these three medications were not administered on 02/23/26 for that reason. Based on 28 opportunities for medication administration and three omissions, the medication error rate was calculated at 10.7%. Review of the facility’s “Administering Medications” policy, last reviewed 04/28/25, stated that medications must be administered in accordance with orders, including required time frames. This deficiency was investigated under Complaint Numbers 2629125 and 1266301.
Medication Allergy and Transdermal Patch Administration Errors
Penalty
Summary
The deficiency involves the facility’s failure to prevent significant medication errors, including administering a medication to a resident with a documented allergy and not properly managing transdermal patch therapy. One resident with multiple diagnoses, including ovarian cancer, dementia, anxiety, depression, diabetes, and dysphagia, was admitted with documented allergies to Trazodone and Meloxicam, with noted reactions such as increased depression, aggression, abdominal pain, and nausea. Her care plan and pre-admission history and physical both identified these allergies. Despite this, after a pharmacy recommendation suggested Trazodone as an alternative to Hydroxyzine for insomnia and anxiety, the physician agreed and ordered Trazodone 50 mg daily, which was started and administered on multiple occasions. Review of the resident’s Medication Administration Record showed that she received Trazodone, a medication to which she was allergic, on five separate dates before the allergy was recognized and the medication discontinued. A progress note later documented by an RN indicated awareness that the resident had an allergy to Trazodone, and the physician was notified and changed the order to Melatonin, discontinuing Trazodone. The DON confirmed that the resident had previously had an order for and was administered Trazodone despite the documented allergy. A second deficiency involved another resident with diagnoses including type 2 diabetes mellitus, ataxia, hyperlipidemia, facial weakness following cerebrovascular disease, anxiety, dysphagia, and cognitive communication deficit, who had intact cognition but was dependent for all mobility and hygiene needs. This resident had an order for a Rivastigmine 24-hour transdermal patch for dementia, with explicit instructions to change the patch daily, place it on different areas of the body, and remove the old patch before applying a new one. During observation of incontinence care and a bed bath, the resident was found to have two Rivastigmine patches on the left shoulder/chest area, one dated for the current day and one for the previous day. An LPN verified the presence of both patches and stated she had removed a patch earlier that morning when applying the new one, indicating the resident must have had three patches on at the same time. Manufacturer instructions and facility policy required removal of the previous day’s patch and administration of medications in accordance with orders, which was not followed in this case.
Failure to Provide Timely Constipation Treatment
Penalty
Summary
The facility failed to provide timely treatment for constipation, resulting in actual harm to a resident who was admitted to the hospital with abdominal pain and stool impaction. The resident, who had intact cognition and was occasionally incontinent of bowel, was at risk for constipation as noted in their care plan. Despite having physician orders for various constipation treatments, including sennosides-docusate sodium, Dulcolax suppository, Milk of Magnesia, and polyethylene glycol, the resident did not receive any as-needed interventions for constipation between January 29 and February 4, 2025, during which no bowel movements were documented. The facility's bowel elimination policy required interventions if a resident had been without a bowel movement for 48 hours, escalating to more aggressive treatments if no results were achieved. However, the resident did not receive any as-needed medications until February 5, 2025, after seven days without a bowel movement. The resident was eventually given an enema and Milk of Magnesia, but continued to experience severe abdominal pain and was admitted to the hospital, where a manual disimpaction was performed. Interviews with the resident and the Director of Nursing confirmed the lack of timely interventions, which contributed to the resident's hospitalization.
Failure to Provide Adequate Nutritional Interventions for Residents
Penalty
Summary
The facility failed to provide adequate nutritional interventions for two residents experiencing significant weight loss. Resident #31, who was admitted with dehydration and moderate protein-calorie malnutrition, experienced a 13.5% weight loss over a short period. Despite a physician's order for a sugar-free healthshake with meals, observations revealed that the supplement was not consistently provided with Resident #31's meals. Interviews with staff confirmed the absence of the supplement on meal trays, and the dietary manager indicated that supplements were typically given between meals, contrary to the physician's order. Resident #60, diagnosed with dementia and dysphagia, also experienced significant weight loss, with a recorded 8.1% loss over 30 days and 12% over 180 days. Despite the weight loss, the resident's dietary interventions were not adjusted in a timely manner. The registered dietitian did not recommend new interventions after the initial weight loss and only suggested double portions months later. Observations showed that Resident #60 did not receive double portions as ordered, and the dietary staff had to adjust the meal portions after realizing the oversight. The facility's policy required reweighing residents with a weight change of 5% or more, but this was not consistently followed. The registered dietitian acknowledged the failure to document and assess the significant weight changes promptly. The lack of timely and appropriate nutritional interventions for both residents highlights deficiencies in the facility's weight management and dietary practices.
Deficiency in Dialysis Care Monitoring and Documentation
Penalty
Summary
The facility failed to provide adequate monitoring and documentation of dialysis care for two residents, both of whom required hemodialysis. Resident #21, who was cognitively intact and dependent on renal dialysis, had multiple instances where pre and post-dialysis evaluations were not completed. The facility had an order to monitor the resident's arteriovenous (AV) fistula for bruit and thrill every shift, but this was not consistently documented or scheduled, leading to missed evaluations. Interviews revealed that the resident himself had to remove the Band-Aid after dialysis, indicating a lack of staff involvement in post-dialysis care. Similarly, Resident #24, who also had end-stage renal disease and was on dialysis, did not have proper documentation or orders for monitoring a newly created fistula. The resident had a history of a clogged fistula and was using a port for dialysis, but a new fistula was created on the left upper arm. Despite the standard practice of checking the thrill and bruit of a fistula, there was no system in place for documenting these checks, and no orders were found for monitoring the new fistula site. Interviews confirmed that while checks were performed by some staff, there was no consistent documentation or directive for others to follow. The facility's policy on dialysis care required that the bruit and thrill of the fistula be assessed every shift and recorded on the Medication Administration Record. Additionally, assessments were to be completed before and after each dialysis session. However, these protocols were not followed, leading to a lack of communication and documentation regarding the residents' dialysis care. The failure to adhere to these policies resulted in deficiencies in the monitoring and documentation of dialysis care for both residents.
Medication Administration Failures in LTC Facility
Penalty
Summary
The facility failed to ensure that residents received medications as ordered, affecting two residents. Resident #123, who was admitted with metabolic encephalopathy and type 2 diabetes mellitus, did not receive her prescribed doses of Lactulose Oral Solution on multiple occasions due to the medication being on order or in transit from the pharmacy. This resulted in missed doses on 03/11/25, 03/24/25, and 03/25/25, as documented in the Medication Administration Record (MAR) and progress notes. Interviews with the resident and staff confirmed the lack of medication availability and administration. Resident #21, admitted with a diagnosis of dysfunctional dyspepsia, did not receive the prescribed Tenapanor for irritable bowel syndrome. The medication was not available from the pharmacy, and there was a lack of communication with the physician regarding this issue. The Director of Nursing (DON) noted the absence of the medication in a progress note, but no further action was taken until the surveyor's inquiry. The medication was not administered, and the pharmacy later indicated that the medication had fallen off their list and needed to be reordered. The deficiencies highlight a failure in the facility's pharmaceutical services, specifically in ensuring timely medication delivery and communication with healthcare providers. Both residents were cognitively intact and aware of the missed medications, which were critical for managing their respective health conditions. The facility's inability to provide these medications as ordered resulted in a lapse in care for the affected residents.
Delayed Response to Pharmacy Recommendations for Psychotropic Medications
Penalty
Summary
The facility failed to ensure timely responses to pharmacy recommendations for residents on psychotropic medications, affecting three out of five residents reviewed. For Resident #11, the facility did not ensure that a physician addressed the pharmacist's recommendations for medication evaluations and reviews, as none of the Physician Recommendation Forms were signed by a physician. This included evaluations for medications such as hydroxyzine, Trazadone, Quetiapine, Buspirone, and Duloxetine over several months. The Director of Nursing confirmed that these forms had not been signed or addressed by a physician. For Resident #60, there was a delay in responding to a pharmacy recommendation for laboratory tests to be drawn every six months. Although the physician agreed to the recommendation, the order for the tests was not noted until over a month later, and the tests were conducted shortly thereafter. Resident #62 experienced a delay in the implementation of a pharmacy recommendation for a gradual dose reduction of olanzapine. The recommendation was made in November, but the dose reduction was not ordered until February. The Director of Nursing confirmed the facility's failure to respond timely to the pharmacy recommendations for these residents.
Failure to Administer Insulin as Ordered
Penalty
Summary
The facility failed to ensure that a resident received insulin as ordered by the physician, resulting in significant medication errors. A resident with a diagnosis of type 2 diabetes mellitus did not receive her morning insulin doses on time. The resident was scheduled to receive Humalog insulin injections at specific times, but the doses were administered late. An LPN, who was working infrequently at the facility, confirmed that the insulin doses were overdue. The Regional Clinical Support Nurse also confirmed that the morning doses were given late. Additionally, the resident was supposed to receive Tresiba insulin daily, as per hospital discharge orders. However, the resident only received one dose on the day of admission, and subsequent doses were not administered. The Director of Nursing confirmed that the pharmacy canceled the order for Tresiba with the intention of replacing it with a generic version, but the order for the generic version was never confirmed. As a result, the resident did not receive the prescribed Tresiba doses after the initial administration.
Infection Control Deficiencies in Insulin Administration and Contact Precautions
Penalty
Summary
The facility failed to ensure proper infection prevention and control practices during the administration of insulin injections and the use of glucometers. An LPN administered insulin to three residents without wearing gloves, which was confirmed through observation and staff interview. Additionally, the LPN did not disinfect a glucometer between uses on two residents, contrary to the facility's policy on cleaning and disinfection of resident-care items and equipment. Furthermore, the Director of Nursing (DON) did not adhere to contact precautions when entering a resident's room who was on contact precautions due to an infection. The DON entered the room without wearing a gown or gloves, handled the resident's personal items, and failed to perform hand hygiene before entering another resident's room to provide assistance. These actions were observed and confirmed through an interview with the DON, who acknowledged the failure to follow proper infection control protocols.
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Illustrative
What surveyors actually found near you
We read the 90 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Defiance
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Laurels Of Defiance The | 1.8 mi | ★★★★★ | 0 | 0 |
| Vancrest Health Care Ctr Of Ho | 13.1 mi | ★★★★★ | 6 | 0 |
| Lutheran Home | 14.4 mi | ★★★★★ | 0 | 0 |
| Northcrest Rehab And Nursing Center | 14.9 mi | ★★★★★ | 1 | 0 |
| Majestic Care Of Bryan | 15.5 mi | ★★★★★ | 19 | 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.