Brookview Healthcare Center

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that drugs and biologicals stored in the central supply closet were free of expired items and were maintained in accordance with the facility policy on medication storage. During observation of the central supply closet with an LPN, surveyors found multiple expired items stored in the closet, including five boxes of Assure Prism Control Solution expired on 12/27/2025, three bottles of Nephro Vitamins C and B Complex expired on 08/2025, three bottles of Flush Free Niacin expired on 10/2024, two bottles of Procure Allergy Relief expired on 08/2025, one bottle of Oyster Shell Calcium expired on 11/2025, one bottle of Liquid Iron Supplement expired on 12/2025, and twelve bottles of Hydrogen Peroxide expired on 05/2025. The observation also identified one bottle of Major Deep Sea Premium Saline Nasal Moisturizer with no expiration date listed. During interview, the LPN stated the expired items should have been wasted and not stored in the central supply room and acknowledged the expired medications. The Administrator later observed the expired medications and controlled solutions and acknowledged that expired medications should not have been stored in the central supply closet.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to send the required notice of transfer or discharge to the representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 residents reviewed for discharges, R122. Review of the facility’s Transfer and Discharge Policy stated that resident transfers and discharges are to be handled in accordance with applicable federal and state regulations and that the facility maintains a process to ensure resident rights, safety, and appropriate notice requirements are met. R122’s face sheet showed the resident was admitted to the facility and was discharged on 12/18/25 against medical advice (AMA). A discharge document titled "Against Medical Advice" dated 12/18/25 showed R122 and two staff witnesses signed the AMA release and the resident was discharged from the facility. However, the facility’s December 2025 Nursing Home Transfer and Discharge Notice Spreadsheet sent to the ombudsman on 01/01/26 did not include R122’s AMA discharge. During interview, the admission director stated she was unaware that this discharge notification needed to be sent to the ombudsman’s office and said it was not done.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to develop a comprehensive, resident-centered care plan for Resident 72 that addressed the resident’s use of vaping products. Review of the facility’s vaping policy showed that vaping within the nursing home was governed by policy in compliance with SCDHEC and CMS regulations. Record review identified Resident 72 as a resident who vapes, and the resident had signed vaping education and consent on 02/16/21. Review of Resident 72’s care plan on 01/07/26 showed there was no care plan present related to vaping status. During interview, Resident 72 stated she does vape, that the facility does not allow residents to smoke cigarettes, and that staff hold onto her vape until she wants to smoke. The MDS Coordinator stated residents who use vaping products should have this addressed in their care plans and confirmed that Resident 72 did not have a care plan addressing vaping. The Administrator also stated that residents who use vapes should be care planned for the use of vapes.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to revise resident care plans to reflect current needs and interventions for two residents reviewed for care plans. One resident had diagnoses including dementia, psychosis, insomnia, and schizoaffective disorder. The resident’s physician order showed memantine 5 mg once daily in the morning, but the comprehensive care plan still listed memantine 10 mg twice daily and included approaches stating memantine 10 mg PO twice a day per MD order, with a discontinuation date of 5/21/25. The care plan was last reviewed and revised on 01/08/26, but the approaches and interventions did not reflect the resident’s current medication orders. Another resident had diagnoses including a pressure ulcer of the right heel, a non-pressure chronic ulcer of the right ankle, pressure-induced deep tissue damage of the left heel, and congestive heart failure. The physician order showed lorazepam 1 mg three times a day for restlessness and agitation, but the comprehensive care plan still identified lorazepam 1 mg PO every eight hours PRN and stated to administer medication as ordered by the medical physician. During interviews, the MDS Coordinator stated care plans are reviewed by her and another MDS nurse each morning, the Administrator stated care plans should be updated at least quarterly and with any change in condition or new concerns, and an LPN stated nursing staff did not update care plans and that it was done by the MDS Coordinator.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure and document that a resident received baths on the designated bath dates between 12/19/25 and 01/03/26. The resident had diagnoses including lack of coordination, muscle weakness, cerebral palsy, dementia, mood disturbance, and anxiety. The quarterly MDS showed a BIMS score of 15/15, indicating the resident was cognitively intact, and also documented upper extremity impairment on one side, lower extremity impairment on both sides, and dependence for all self-care and mobility needs. The care plan stated the resident required substantial to dependent assistance with most ADLs and needed transfers with a Hoyer lift and two staff members. Review of the ADL record did not show documentation of a bath or shower during the reviewed period, and the progress notes did not show any refusals of ADL care for the six months reviewed. During observations, the resident's hair appeared greasy with multiple areas of dandruff. A CNA stated the resident sometimes missed baths because of staffing shortages or issues with the Hoyer lift, and that the floor did not have enough staff to transport the resident to and from the shower room due to the level of assistance required. An LPN stated that if the floor was short-staffed for the Hoyer lift, the resident might not receive a shower but would be given a bed bath. The Administrator stated the resident had gotten baths but they may not have been documented, and that staff were expected to document all baths and showers given to residents.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

A deficiency occurred when a resident with a history of vascular dementia, anxiety, and disorganized thinking was not provided with adequate supervision to prevent elopement. The resident had a documented pattern of exit-seeking behavior, as noted in multiple progress notes over several days, including attempts to open doors, triggering door alarms, and verbalizing intentions to leave. The care plan identified the resident's cognitive impairments and directed staff to orient the resident, protect from self-injury, and maintain a calm environment, but did not specify enhanced supervision or elopement precautions despite the ongoing exit-seeking. On the day of the incident, staff failed to account for the resident during shift change. There was confusion among CNAs regarding the resident's whereabouts, with assumptions made that the resident was in another unit. The resident was ultimately discovered missing after a CNA could not locate her in the building. Staff initiated a search, and the resident was found by a dietary staff member at a local grocery store over a mile away, standing partially in the road. The resident was returned to the facility without injury, but interviews revealed that staff did not consistently perform end-of-shift rounds or communicate effectively during shift reports, and that the resident had previously exited the building without being noticed. Facility observations and staff interviews indicated that the exit doors were equipped with coded keypads and alarms, but the alarm volume was minimal and not always audible from resident rooms. The resident was able to exit through a door by holding the lever for 15 seconds, as indicated by signage. Staff reported that the facility did not utilize a Wanderguard system, and that some doors could be opened if leaned on. The lack of effective supervision, insufficient alarm audibility, and inconsistent staff practices contributed to the resident's unsupervised exit from the facility.

Removal Plan

• A body audit was completed on Resident #4 upon return to the facility.
• Resident was immediately placed on 15 minute checks.
• Staff in service on elopement prevention and CMS guidelines were conducted.
• Head count conducted for the entire facility following the elopement.
• Maintenance director checked all doors throughout the building.
• A professional contractor was contacted to complete a facility-wide inspection of all door alarms and perform any necessary corrective work.
• The contractor will also evaluate and adjust alarm volume upward, as needed, to ensure maximum audibility throughout the facility.
• Elopement risk assessments completed on admission, quarterly and with significant changes.
• Elopement drill conducted.
• All new hires receive dementia management training.
• The nursing department receives further education on dementia/wandering residents annually and as needed throughout the year.
• Door alarm inspections will be increased to daily from weekly by the maintenance staff.
• Inservice to be provided to staff regarding any issues with the doors/alarms must be reported directly to the Director of Nursing or the Administrator.
• The facility has set the TELS system, used to document completion of the monitoring, to alert the administrator via email and mobile application that the task was completed.
• The administrator will take findings to QAPI committee monthly for three months and quarterly thereafter until the issue is deemed to require no further issue.

Penalty

Inspection fine: $11,910

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to protect a resident from sexual abuse, as evidenced by an incident involving two residents. One resident, who had a history of wandering and cognitive impairment, entered another resident's room and was found naked on top of the resident. This incident was observed by staff members, who intervened and removed the resident from the room. The affected resident, who had severe cognitive impairment and was non-ambulatory, was unable to communicate effectively about the incident. The facility's policy on abuse and neglect prohibition was not effectively implemented, as staff did not immediately report the incident as a potential sexual assault. The Director of Nursing (DON) and other staff members assessed the resident and determined there were no signs of physical trauma, leading them to conclude that the incident was not reportable. However, the resident's family was not notified promptly, and the decision not to send the resident to the hospital for further evaluation was made without thorough documentation or consideration of the resident's cognitive limitations. The facility's response to the incident was inadequate, as the staff failed to recognize the severity of the situation and did not follow proper reporting procedures. The lack of immediate action and communication with the resident's family contributed to the deficiency, highlighting a failure to protect residents from abuse and ensure their safety. The incident was later reported to the police, and the resident involved in the abuse was sent to a psychiatric unit for evaluation.

Removal Plan

• Resident was sent to the Hospital Psychiatric Unit.
• Resident was checked for any signs and symptoms of abuse. She was sent to hospital for further evaluation.
• Resident did not recall the incident occurring.
• All staff will receive additional training on Sexual Abuse by the Staff Development Coordinator.
• The DON was provided with additional training on reportable incidents by the Administrator.
• The Administrator will be notified in addition to the Director of Nursing of all unusual occurrences involving two residents.
• All staff will be educated to the update of this procedure by the Staff Development.
• All incident reports will be brought to the Morning Meeting for review.
• The Administrator will monitor these incidents to ensure that any resident/resident incidents were reported to her.
• Administrator will take findings of this monitoring tool to the QAPI committee monthly for three months and quarterly thereafter until the issue is deemed to require no further review.

Penalty

Inspection fine: $11,910

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to report an alleged incident of sexual abuse involving two residents to the State Survey Agency (SSA). The incident occurred when a resident with dementia was found naked on top of another resident, who also has dementia, in her room. The staff, including a Licensed Practical Nurse (LPN) and a Registered Nurse (RN), intervened and removed the male resident from the room. Despite the situation, the Director of Nursing (DON) and the staff did not report the incident to the SSA, as they believed there was no evidence of penetration or sexual assault since the female resident's brief was intact and there were no visible injuries. The incident was later brought to light when the female resident's family contacted the Ombudsman, who then became aware of the situation. The facility's policy requires immediate reporting of such incidents to the state agency and law enforcement, but this protocol was not followed. The DON acknowledged the failure to report and apologized to the resident's family for not notifying them promptly. The Administrator confirmed that the incident should have been reported and expressed uncertainty as to why the DON did not fulfill this responsibility.

Penalty

Inspection fine: $15,043

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide appropriate supervision to prevent the elopement of a resident, identified as R1, who successfully left the premises without supervision. R1 was last seen by a CNA ambulating in the hall around 6:00 PM, but by 7:00 PM, the CNA noticed R1 was not in her room and alerted a nurse. Despite a search of the unit and facility, R1 was not found on the premises. It was later discovered that R1 had obtained a ride from college students at a neighboring apartment and went to a friend's house. R1 was returned to the facility by local police with bruises on her right eye, right hand, and right arm. R1's medical history included generalized anxiety disorder, vascular dementia, and unspecified dementia with other behavioral disturbances. However, an elopement evaluation conducted on 01/23/2025 revealed no elopement risk factors, and an elopement care plan was not deemed necessary. R1's Admission Minimum Data Set (MDS) indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15, suggesting no cognitive impairment, and no wandering behaviors were noted. Despite this, R1 was upset about a dress belonging to another resident, which may have contributed to her decision to leave the facility. Interviews with staff revealed that the facility's elopement response was initiated once R1 was discovered missing, but the search was unsuccessful until the police intervened. The facility's policy, titled Elopement Response Guidelines, emphasizes the responsibility of all staff to provide a safe environment for residents. However, the incident highlighted a failure in supervision and monitoring, as well as potential issues with the facility's door alarms, which were reported to have problems by staff. R1 expressed dissatisfaction with the facility, citing theft and a lack of support as reasons for her departure.

Removal Plan

• A body audit was done on Resident #1 upon return to the facility.
• Resident was placed on 15 minute checks.
• Emotional support was provided to resident by the Director of Nursing.
• Inservice was completed to all staff by the Staff Development Coordinator and Director of Nursing on CMS guidelines regarding elopement.
• Maintenance staff checked and recorded that all doors on units with residents who are at risk for elopement were found to be in working order.
• A professional contractor was brought into the building to inspect all alarms and provide any work required if issues were found.
• The facility requested a quote from the contractor to upgrade all door monitoring alarms in the facility.
• Door alarms inspections were increased from weekly to daily by the maintenance staff.
• Inservice will be provided to staff regarding any issues with the doors/alarms must be reported directly to the Director of Nursing or Administrator.
• The facility has set the TELS system, used to document the completion of the monitoring, to alert the administrator via e-mail and mobile application that the task was completed.
• Administrator will take findings of this monitoring tool to the QAPI committee monthly for three months and quarterly thereafter until the issue is deemed to require no further review.

Penalty

Inspection fine: $15,646

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to ensure that food items were properly stored and maintained below 41 degrees Fahrenheit, which is essential to reduce the potential of foodborne illnesses. During an initial tour of the kitchen, several issues were observed, including dented cans, improperly stored and labeled food items, and a sugar bin without a scoop. The walk-in refrigerator was found to have an internal temperature of 60 degrees Fahrenheit, with ice accumulation and a black substance on the fan's pipes. The Dietary Manager admitted that the refrigerator had been down but was operational on the day of the observation. Further observations revealed expired and improperly labeled food items in the walk-in refrigerator, such as containers of cottage cheese and macaroni salad. The meat freezer was found with a puddle of water on the floor and boxes of food items actively defrosting. The internal thermometer of the meat freezer was unreadable, and the external thermometer displayed an error code. Interviews with staff revealed inconsistencies in temperature monitoring and documentation, with some staff unaware of the proper temperature requirements for refrigerators and freezers. Residents reported dissatisfaction with the food quality, with one resident mentioning receiving spoiled milk and another describing meals as cold and unidentifiable. The facility's temperature logs showed incomplete and inaccurate documentation, with missing initials and incorrect temperature readings. Despite staff claims of no issues with the equipment, observations consistently showed malfunctioning refrigerators and freezers, leading to the discarding of food items that did not meet safety standards.

Penalty

Inspection fine: $15,646

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to maintain appropriate Registered Nurse (RN) staffing for 8 hours a day on multiple occasions. Specifically, on January 17, February 10, and February 24, 2024, the facility did not have an RN present for 8 consecutive hours, as evidenced by the review of the facility's daily schedule and Patient Per Day Posting. During interviews conducted on August 15, 2024, the Director of Nursing (DON) and the Staffing Coordinator acknowledged the absence of an RN for the required duration on these dates. The DON also revealed that the facility lacks a specific policy related to staffing, instead following federal regulations.

Penalty

Inspection fine: $15,646

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to provide a policy regarding the handling and monitoring of outside food brought into the facility. This deficiency was identified during a survey of the main kitchen. During interviews, both the Dietary Manager and the Administrator confirmed that there was no existing policy related to personal food brought in by family or other visitors for residents. This lack of policy was noted as a deficiency in the facility's operations.

Penalty

No penalty information released

The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

The facility failed to prohibit the misappropriation of property for two residents, R3 and R4, related to missing medications. R3, who was admitted with diagnoses including anxiety, pain, chronic obstructive pulmonary disease, and gastro-esophageal reflux disease, reported not receiving her prescribed Hydrocodone-acetaminophen on one occasion despite being in severe pain. Record reviews showed discrepancies in the Controlled Drug Record (CDR) with unrecognized signatures and missing documentation in the Medication Administration Record (MAR). Similarly, R4, admitted with diagnoses including a left femur fracture, muscle weakness, and left hip pain, also reported not receiving her prescribed Hydrocodone-acetaminophen. The CDR for R4 showed multiple instances of unrecognized signatures and missing documentation in the MAR. During interviews, both residents confirmed they did not receive their medications on specific dates. The Director of Nursing (DON) acknowledged that the medication cart count was correct but noted irregularities in the medication sign-out process, including mismatched signatures and incorrect dates. An attempt to contact the alleged nurse through the staffing agency was unsuccessful, as the agency was unable to provide the nurse's information without further authorization.