Above average — CMS composite of the measures below.
The next survey window likely opens 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 Brookwood Care Center during CMS and state inspections, most recent first.
Hair Restraints Not Fully Covering Dietary Staff Hair: Dietary staff were observed in the kitchen without effective hair restraints while preparing fruit and handling clean dishes. One aide had a ponytail uncovered, another wore a hairnet that left a braid exposed, and another had hair exposed in the back; the DON and other leadership stated all hair should be covered, while staff gave conflicting understanding of the requirement.
The facility failed to maintain safe and comfortable indoor temperatures when one floor experienced room and hallway temperatures above the facility’s stated 71°F–81°F range on multiple days. Resident council minutes documented ongoing concerns about non-functioning AC, and staff including an RN, an LPN, a STNA, the DON, and the Administrator confirmed that the AC stopped working during the summer, residents complained frequently about the heat, and alternative cooling measures such as fans and ice water were used while temperatures remained above the policy limits.
A facility failed to serve food in the proper form for residents with mechanical soft diet orders during lunch. Staff placed regular grilled ham and cheese sandwiches on the steam table instead of ground sandwiches, and residents on mechanical soft diets were served whole red grapes instead of applesauce. Staff gave conflicting explanations about which diet references to use, while the RD stated residents on mechanical soft diets should not have been served grapes because they had chewing or swallowing problems.
Failure to provide NOMNCs for 3 residents with Medicare Part A stays. The facility did not have beneficiary notification policy, and SNF Beneficiary Notification Reviews showed the CMS-10123 was not given to residents or their reps before discharge. One resident had moderate cognitive impairment, while two residents had intact cognition based on BIMS scores; the ADM stated the notices were the responsibility of a former SW and could not be located.
Failure to Timely Report Alleged Resident Abuse: A resident with intact cognition reported that another resident grabbed and shook the resident’s arm or wrist after the resident declined contact, causing pain and prompting nursing assessment and an X-ray. Facility leadership discussed the event and determined there was no malicious intent, but the ADM did not report the allegation to ODH within the required 2-hour timeframe, stating the matter had already been investigated and police had been contacted after the window had passed.
Incomplete Investigation of Resident-to-Resident Abuse Allegation: A resident with intact cognition reported that another resident grabbed and shook the resident’s wrist or hand, causing pain. Nursing staff notified the physician and obtained an X-ray, but the investigation was not thorough: the SSD obtained no additional statements, no other residents were interviewed, and the ADM later acknowledged the matter should have been handled as a more formal abuse investigation. Staff descriptions of the event varied, and law enforcement was contacted after the resident requested to report the incident.
Failure to Include PTSD in Person-Centered Care Plans: Two residents with PTSD had care plans that did not address PTSD, identify triggers, or include interventions. Staff, including STNAs and an LPN, were unaware of the residents’ PTSD or triggers, and the MDS coordinator stated PTSD interventions and triggers were not placed on the care plan. One resident described fear during care related to a prior traumatic injury, while BH notes documented PTSD for both residents.
A resident with severe cognitive impairment had hydrocortisone cream and antacids observed in the room even though there were no active orders for either medication and no order for self-administration. Staff stated residents were not allowed to keep medications in their rooms unless approved, and the DON and Administrator both stated medications should not be stored in resident rooms, especially for cognitively impaired residents.
Staff failed to follow EBP PPE requirements for a resident with a feeding tube, urinary catheter, ostomy, and wound. During wound care, a PTA did not wear a gown, and during transfer assistance, an STNA was also observed without a gown despite EBP signage being on the door. The resident’s care plan required gloves and gowns for high-contact care, and the PTA stated she did not see the signage and was unaware PPE was required.
Survey results were not readily accessible for resident and visitor review. The lobby binder titled Resident Information Book contained only federal and state survey results from 2020 through 2021, with no reports posted after the 03/04/2021 complaint survey. The REC confirmed there were no other lobby locations for survey reports, the DON expected survey information to be easily available, and the ADM confirmed the most recent survey reports were not in the binder or otherwise easily accessible.
The facility failed to protect residents' confidential information by posting papers with names, room numbers, and care details in a public hallway. Staff confirmed this practice was routine to inform nurse aides of care duties, affecting 14 residents. This breach was discovered during a complaint investigation.
A resident with multiple health conditions requiring assistance with ADLs did not receive consistent nail care, as observed by surveyors. The resident's care plan included regular showers and staff assistance, but records showed only bed baths were provided, with no documentation of nail care. Observations and interviews confirmed overgrown and jagged nails, indicating a failure to adhere to the facility's ADL care policy.
A facility failed to maintain resident privacy when an STNA took and shared a photo of a resident with severe cognitive impairment without consent. The resident, who required assistance with daily activities, was photographed sitting in bed. This action violated the facility's policy on resident rights, which prohibits taking photos without written consent.
A facility failed to provide timely incontinence care to a resident with central cord syndrome and neurogenic bowel, who was dependent on staff for all activities of daily living. The resident's care plan required checks and changes every three hours, but during an observation, the resident was found with saturated incontinence brief, sweatpants, and Hoyer pad. Interviews with STNAs revealed the resident had not been attended to since the start of their shift, leading to a lapse in care.
Hair Restraints Not Fully Covering Dietary Staff Hair
Penalty
Summary
The facility failed to ensure dietary staff wore effective hair restraints while working in the kitchen. The 2022 FDA Food Code and the facility’s Employee Hygiene for Food Safety policy required food employees to wear hair restraints designed to keep hair from contacting exposed food, clean equipment, utensils, linens, and unwrapped single-service and single-use articles. During lunch meal service observations, Dietary Aide #9 was preparing bowls of fruit with his hair in a ponytail down his back and no hair covering. Dietary Aide #10 was observed in the kitchen without a hairnet, then later placed a hairnet on the top of her hair with a braid uncovered down her back. Dietary Aide #11 was observed unloading clean dishes with a hairnet on the top of his hair while approximately four inches of hair remained uncovered in the back. The Director of Food Services was also observed in the kitchen with the front part of her hair uncovered by the hairnet. Staff interviews showed differing understanding of the requirement, including statements that only the top part of the hair needed to be covered, while other staff and leadership stated all hair should be covered.
Failure to Maintain Safe and Comfortable Indoor Temperatures
Penalty
Summary
The deficiency involves the facility’s failure to maintain resident room and hallway temperatures within the facility’s own stated comfort range of 71°F to 81°F, resulting in temperatures exceeding 81°F on multiple days. The facility’s Quality of Life – Homelike Environment policy, revised in May 2017, required that residents be provided with a safe, clean, comfortable, and homelike environment, including comfortable and safe temperatures between 71°F and 81°F. Resident Council meeting minutes from June and July 2025 documented resident concerns that the air conditioning was not working. Review of the facility’s temperature log for one hall on the third floor showed recorded temperatures of 82°F to 83°F on six separate days in June 2025. Staff interviews confirmed that the air conditioning stopped working during the summer months and that residents complained about hot temperatures. A registered nurse reported that the AC stopped working in June and July 2025 and that the facility obtained fans for resident rooms and hallways. A state tested nurse aide stated it was hot during the summer of 2025 and that residents had fans and were provided ice water. An LPN reported that residents complained a lot about the heat and that staff offered cool washcloths and took residents out of their rooms when tolerated. The DON acknowledged that the facility used a boiler system for cooling that made temperature control difficult, confirmed that administration received complaints from residents about hot temperatures, and stated that temperature logs showed readings above 81°F for six days in June 2025. The Administrator confirmed the expectation that temperatures remain between 71°F and 81°F to keep residents safe and comfortable.
Mechanical Soft Diet Meals Not Served as Ordered
Penalty
Summary
The facility failed to ensure residents received food prepared in a form designed to meet individual needs during the lunch meal. The facility had 11 residents with physician-ordered mechanical soft diets, including 10 residents on mechanical soft diets and one resident on a pureed diet that allowed mechanical soft pleasure foods. The lunch menu for the meal indicated that residents on a mechanical soft diet were to receive a ground grilled ham and cheese sandwich instead of a regular grilled ham and cheese sandwich, along with applesauce in place of red grapes, and the recipe specified that the meat should be ground to the desired consistency for mechanical soft diets. During observation, grilled ham and cheese sandwiches were placed on the steam table, but no ground sandwiches were observed. Later, residents with mechanical soft diet orders were served whole red grapes. A dietary aide stated that the cook sometimes chopped dessert for mechanical soft diets but did not do that for the grapes that day. Another staff member stated he served a regular sandwich because he believed residents on a mechanical soft diet could eat a lunch meat sandwich. The DS stated staff relied on the meal ticket for diet information, while the DFS and RD stated staff were supposed to use the diet spreadsheet, menu spreadsheet, and recipes to know what to serve. The RD stated residents on a mechanical soft diet should not have been served grapes and needed the correct diet because they had chewing or swallowing problems.
Failure to Provide Medicare Non-Coverage Notices
Penalty
Summary
The facility failed to provide the required Notice of Medicare Non-Coverage (NOMNC), Form CMS-10123, for 3 residents reviewed for beneficiary notification. The Administrator stated the facility did not have a policy for beneficiary notification, and the facility’s Entrance Conference Worksheet identified 13 residents discharged home from Medicare Part A services with benefits remaining, including the 3 residents cited in the deficiency. For Resident #80, the record showed admission on 08/14/2025 and discharge on 09/06/2025; the admission MDS documented a BIMS score of 12, indicating moderate cognitive impairment, and the SNF Beneficiary Notification Review showed the NOMNC was not provided to the resident or representative before discharge. Resident #130 was admitted on 10/08/2025 and discharged on 11/15/2025. The discharge MDS documented a BIMS score of 14, indicating intact cognition, and showed the most recent Medicare stay ran from 10/08/2025 through 11/14/2025. Resident #131 was admitted on 10/06/2025 and discharged on 12/17/2025; the discharge MDS documented a BIMS score of 15, indicating intact cognition, and showed the most recent Medicare stay ran from 12/05/2025 through 12/16/2025. For both residents, the SNF Beneficiary Notification Review showed the NOMNC was not provided to the resident or representative before discharge. During interviews, the Administrator stated the letters were the responsibility of a previous social worker who was no longer employed and that current staff could not locate the letters.
Failure to Timely Report Alleged Resident Abuse
Penalty
Summary
The facility failed to report an allegation of abuse to the state agency within the required timeframe for one resident. The facility policy stated that any alleged abuse must be reported to ODH immediately, but not later than 2 hours after the allegation is made. Resident #35 was admitted with diagnoses including conversion disorder, major depressive disorder, repeated falls, and a history of traumatic brain injury, and had a BIMS score of 15 indicating intact cognition. Resident #44 was also cognitively intact, was dependent on staff for transfers, used a motorized wheelchair, and had care plan concerns related to disruptive interactions, resisting care, and noncompliance with medications. Resident #35 reported that Resident #44 grabbed and shook the resident’s arm or wrist after the resident declined the other resident’s request for hand contact or to make decorations. Nursing staff documented that Resident #35 complained of wrist pain and that the supervisor and physician were notified, with an X-ray ordered. A handwritten statement from the Social Services Director and later interviews reflected that Resident #35 described the interaction as Resident #44 grabbing both arms or shaking the hand too hard, causing pain. The X-ray showed no fracture or dislocation, and staff noted no bruising or discoloration, though some swelling or edema was mentioned by some staff. Facility staff and leadership were aware of the incident and discussed it among themselves, but the Administrator stated the event was not reported to the state survey agency because he believed there was no ill intent or malice and that the interaction was simply Resident #44 being polite. The Administrator also stated that by the time police were contacted, it was already beyond the 2-hour reporting window, and the facility did not report the allegation to the state agency because staff had already investigated it and the police had been involved. The Director of Nursing stated she could appreciate that the incident should have been reported to the state survey agency, and the Administrator later acknowledged that he should have reported it and started a more formal investigation when Resident #35 said they wanted to contact police.
Incomplete Investigation of Resident-to-Resident Abuse Allegation
Penalty
Summary
The facility failed to complete a thorough investigation of an allegation of abuse involving one resident and another resident. Facility policy required that all alleged violations involving abuse, neglect, exploitation, mistreatment, and injuries of unknown source be investigated, including interviewing the resident, the accused, witnesses, and, when appropriate, other residents on the unit. The policy also stated that if there were no direct witnesses, interviews could be expanded to other staff or residents as appropriate. Resident #35 was admitted with diagnoses that included conversion disorder, major depressive disorder, repeated falls, and a history of traumatic brain injury. A quarterly MDS showed intact cognition with a BIMS score of 15 and independence with ADLs. Resident #44 was admitted with diagnoses that included obesity, anxiety, and paraplegia. An annual MDS showed intact cognition with a BIMS score of 15, dependence on staff for transfers, use of a motorized wheelchair, and a care plan that addressed disruptive interactions, resisting care, and noncompliance with medications. Resident #35 reported that Resident #44 grabbed and shook the resident’s wrist or hand, causing pain. Nursing staff documented the complaint, notified the physician, and an X-ray was obtained that showed no fracture or dislocation. A sheriff’s report documented that Resident #35 called in an assault report, and the administrator told law enforcement that Resident #44 had taken Resident #35 by the arm and wrist and shook it while saying, "I just love you." During interviews, staff gave differing descriptions of the event, but several confirmed they did not witness it. The SSD stated no other statements were obtained, and the ADM later acknowledged that other residents were normally interviewed during investigations but none were interviewed in this case. The ADM also stated that when Resident #35 wanted to contact police, he should have reported the incident to the state survey agency and started a more formal investigation.
Failure to Include PTSD in Person-Centered Care Plans
Penalty
Summary
The facility failed to ensure person-centered care plans were developed and implemented for 2 residents with PTSD. Facility policy required trauma-informed care that minimized triggers and re-traumatization and called for collaboration with the resident and, as appropriate, family and health care professionals to develop individualized care plan interventions. Another facility policy stated the interdisciplinary team was responsible for developing an individualized comprehensive care plan for each resident. One resident was admitted with a history of PTSD and had a BIMS score of 14, indicating intact cognition. The resident’s care plan, initiated after admission, did not address PTSD, include interventions for PTSD, or identify PTSD triggers. A BH progress note later documented past psychiatric diagnoses that included PTSD. During interviews, an STNA stated she was unaware the resident had PTSD or any triggers, and another STNA gave the same response. An LPN stated she knew the resident had PTSD and believed it was related to a prior fall and fracture, but also stated the care plan did not contain PTSD triggers and interventions. The resident stated they became very scared when changed and rolled because of a prior incident in which they were pushed out of bed and broke both legs. The second resident was admitted with a history of PTSD and had a BIMS score of 11, indicating moderate cognitive impairment. The resident’s care plan, initiated after admission, did not address PTSD, include interventions for PTSD, or identify PTSD triggers. A BH progress note documented chronic PTSD. During interviews, an STNA and an LPN stated they were unaware the resident had PTSD or any triggers, and the LPN said she would look to the care plan for PTSD triggers if they existed. The MDS coordinator stated PTSD interventions and triggers were not placed on the care plan, and the regional MDS coordinator stated not every resident with PTSD had triggers. The MDS coordinator and regional MDS coordinator were unable to explain how staff caring for the resident would know the resident’s PTSD triggers.
Unprescribed Medications Found in Resident Room
Penalty
Summary
The facility failed to ensure Resident #104’s room remained free of accident hazards when unprescribed over-the-counter medications were found in the resident’s room. Resident #104 was admitted on 03/14/2023 and had diagnoses including emphysema, osteoporosis, muscle weakness, generalized anxiety disorder, and cognitive communication deficit. The annual MDS with an ARD of 12/17/2025 showed a BIMS score of 3, indicating severe cognitive impairment, and the resident required set-up assistance with eating and oral hygiene. The care plan identified cognitive and communication deficits related to forgetfulness and difficulty making decisions, with a goal of maintaining safety. Observations on 01/19/2026 and 01/21/2026 showed a tube of hydrocortisone cream on the bedside table and a bottle of antacids on the dresser in Resident #104’s room. The Order Summary Report showed no active orders for either medication and no order for self-administration. Staff interviews indicated residents were not allowed to keep medications in their rooms unless approved to self-administer, and medications should have orders, including OTC medications. When shown the medications, the LPN stated they should not be in the room, and the resident stated they did not know where the antacids came from. The DON and Administrator both stated medications should not be stored in residents’ rooms, especially for cognitively impaired residents.
Failure to Use Required PPE During EBP Care
Penalty
Summary
The facility failed to ensure staff followed infection prevention and control practices for a resident on Enhanced Barrier Precautions (EBP). Resident #13 was admitted with a history that included gastrostomy status and dependence on renal dialysis, and the quarterly MDS indicated the resident had an indwelling urinary catheter, an ostomy, and one unstageable pressure ulcer. The care plan identified the resident as requiring EBP related to a feeding tube, urostomy, colostomy, and a wound, with interventions directing staff to clean hands before entering and leaving the room, not share gloves and gowns between residents, keep EBP signage on the door, and wear gloves and gowns for high-contact care activities including dressing, bathing, transferring, hygiene, toileting, device care, and wound care. During observation, the EBP sign was present on the resident’s door, but the Physical Therapy Assistant providing wound treatment to the wound on the back of the right thigh was not wearing a gown. In a separate observation, two STNAs were in the resident’s room assisting with a transfer, and one STNA was not wearing a gown. The PTA stated she was unaware the resident required PPE and did not see the signage on the door, and said she would have worn a gown and gloves if she had known. The STNA stated she was assisting the resident to transfer and did not have on a gown. The DON stated she expected staff to ensure the signage was on the door and to follow the signage and orders by wearing the appropriate PPE, and the Administrator stated he expected the facility’s policy and procedures to be followed.
Survey Results Not Readily Accessible
Penalty
Summary
The facility failed to ensure that the results of the most recent surveys were readily accessible for resident and visitor review. On 5 survey days, observations in the lobby showed a binder titled Resident Information Book that contained federal and state survey results only for 2020 through 2021, with no survey results posted after the complaint survey dated 03/04/2021. The facility census was 111, and the deficiency had the potential to affect all residents. During interviews, the receptionist confirmed there were no additional locations in the lobby where survey reports were available to residents and the public, and the administrator confirmed the last report in the binder was from 2021. Although a notice on a third-floor bulletin board stated survey information was located on the kitchen counter of [NAME] Hall, an observation of that kitchen counter did not reveal any survey information, and the wound care clinician stated there was no survey information there. No postings related to the availability of survey inspection reports were observed on Sycamore Hall, and the administrator stated the most recent survey inspection reports were not in the binder nor easily accessible to residents and the public.
Breach of Resident Confidentiality in Public Area
Penalty
Summary
The facility failed to maintain the confidentiality of residents' personal and medical information, as observed during a survey. Papers containing sensitive information, such as resident names, room numbers, and care details, were posted in a public area of the facility. This information was visible on a wall near a mounted computer monitor in a hallway, which served as a workstation for nurse aides. The documents included lists of residents scheduled for morning get-ups, lay-downs, and dining room assignments, affecting 14 residents out of 16 reviewed for privacy. Interviews with facility staff confirmed the practice of displaying these documents publicly. A Certified Nurse Aide (CNA) acknowledged that the papers were always displayed in this manner to inform nurse aides of the care due for residents. A Licensed Practical Nurse (LPN) verified that the documents were visible in a public area and contained personal and clinical information about the residents. This deficiency was identified during a complaint investigation, highlighting a breach in maintaining the confidentiality of residents' information.
Failure to Provide Adequate Nail Care
Penalty
Summary
The facility failed to ensure adequate nail care for a resident, identified as Resident #15, who was unable to perform activities of daily living independently. Resident #15, who had diagnoses including hemiplegia, hemiparesis, vascular dementia, contracture, epilepsy, and type II diabetes, required substantial assistance with personal hygiene and other daily activities. The care plan indicated the need for staff assistance with ADLs and specified the use of a mechanical lift for transfers, as well as regular showers twice a week. However, documentation from shower sheets showed that the resident received bed baths on several occasions, with no records indicating whether fingernail care was offered, provided, or refused. Observations revealed that the resident's fingernails on the left hand were overgrown and jagged, while the right hand's fingernails appeared trimmed. Interviews with the resident and staff confirmed that nail care was not consistently provided with each shower or bath, and there was no documented evidence of nail care being offered or performed. The facility's policy on ADL care emphasized the necessity of services to maintain grooming and hygiene, yet this was not adhered to in the case of Resident #15, leading to the identified deficiency.
Violation of Resident Privacy Due to Unauthorized Photograph
Penalty
Summary
The facility failed to maintain resident privacy when an employee took a photo of a resident without permission and shared it via text message. This incident involved a resident with paranoid schizophrenia and Alzheimer's disease, who had severe cognitive impairment and was unable to give consent. The resident required supervision and assistance with daily activities and had impaired decision-making abilities. The facility's care plan emphasized preserving the resident's dignity, which was compromised by this action. During an interview, a State Tested Nurse Assistant (STNA) confirmed receiving a text message containing a photo of the resident from another STNA. The photo showed the resident sitting in bed, fully dressed, with a blanket over the lower portion of her body. The facility's policy on resident rights clearly stated that taking photographs or recordings of a resident without written consent is a violation of privacy and confidentiality. This deficiency was investigated under a specific complaint number.
Failure to Provide Timely Incontinence Care
Penalty
Summary
The facility failed to provide timely incontinence care to a resident who was dependent on staff for such care. The resident, who was cognitively intact, had diagnoses including central cord syndrome at the C-6 level of the cervical spinal cord, neuromuscular dysfunction of the bladder, and neurogenic bowel. According to the care plan, the resident was to be checked and changed every three hours and as needed, with the call light kept within reach and answered promptly. However, during an observation, it was noted that the resident's incontinence brief, sweatpants, and Hoyer pad were saturated with urine, indicating a lapse in care. Interviews with two State tested Nursing Assistants (STNAs) revealed that they had not attended to the resident since the start of their shift at 7:00 A.M., and the resident had last been changed at 3:00 A.M. The STNAs confirmed that the resident had been in the wheelchair since then, and the incontinence care was not provided in a timely manner. This deficiency was identified during a complaint investigation and was documented under Complaint Number OH00154222.
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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 Cincinnati
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Cottingham Retirement Community | 1.2 mi | ★★★★★ | 15 | 0 |
| Meadowbrook Care Center | 2.8 mi | ★★★★★ | 0 | 0 |
| Majestic Care Of Cedar Village. | 3.7 mi | ★★★★★ | 4 | 0 |
| Lodge Nursing & Rehab Center | 3.7 mi | ★★★★★ | 7 | 0 |
| Twin Lakes | 4 mi | ★★★★★ | 0 | 0 |
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