Above average — CMS composite of the measures below.
The next survey window likely opens around October 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 The Neighborhoods At Brookview during CMS and state inspections, most recent first.
Unattended Hot Oven in Neighborhood Kitchenette: An oven in the Ash Neighborhood kitchenette was left on at 300 degrees with no staff present while four residents were nearby in the dayroom. Observation showed the oven was hot, empty, and unlocked, with unbaked cookies on sheets nearby. Interviews with NS staff, a dietary cook, the RN supervisor, and the administrator confirmed the oven was not being directly monitored, and the FSD stated there was no specific policy for neighborhood kitchenette ovens.
Three residents with varying degrees of cognitive and physical impairment experienced falls or lacked access to recliner controls due to the facility's failure to assess recliner safety, update care plans, and educate staff. Care plans were not revised to reflect changes in residents' conditions or new interventions after falls, and staff were inconsistently informed about recliner safety protocols, resulting in inadequate supervision and accident hazard prevention.
The facility failed to properly label and store food items, resulting in expired juice cartons in kitchenette refrigerators and expired cheese, bacon bits, and milk in the main kitchen cooler. Staff interviews revealed inappropriate practices, such as tasting expired juice, and acknowledged the inadequacy of the expiration date cheat sheet.
A resident experienced significant delays in call light response times, with 82 instances of waits over 20 minutes and the longest being one hour and 21 minutes. The facility's outdated call light system and lack of a specific policy contributed to the deficiency, despite efforts to monitor and improve response times through the QAPI program.
A CNA failed to follow proper glove use and hand hygiene during catheter care for a resident, using the same gloves for multiple tasks without washing hands. Additionally, clean laundry was delivered uncovered, contrary to the facility's infection control policy.
Unattended Hot Oven in Neighborhood Kitchenette
Penalty
Summary
The provider failed to ensure a safe environment when the oven in the Ash Neighborhood kitchenette was left on at 300 degrees and unattended while residents were present in the area. During observation on 9/16/25 at 9:36 a.m., there was an odor suggesting a hot oven, no staff were observed in the kitchenette, covered unbaked cookies were on cookie sheets on the stove and countertop, and the oven temperature light showed 300 degrees. The oven door was not locked and opened easily, and the oven was empty and hot. Four residents, including two with BIMS scores of 15 indicating cognitive intactness and two with BIMS scores of 00 and 01 indicating severe cognitive impairment, were observed in the nearby dayroom. Interviews confirmed that the oven was on without direct monitoring in the kitchenette area. NS D stated she had stepped away and believed the cook in the galley would monitor the oven, while the dietary cook stated he thought the oven should be off if residents were in the area and no staff were there to monitor it, and he did not say he had been monitoring it. The RN supervisor stated it was NS D's responsibility to stay right by the stove when it was on or in use. The food services director stated there was no specific policy for neighborhood kitchenette ovens, only a general safety policy, and the administrator stated he did not see anyone next to the stove when he entered the area.
Failure to Assess and Update Care Plans for Recliner Safety and Fall Prevention
Penalty
Summary
The facility failed to assess and address the safety needs of three out of five sampled residents who either experienced falls related to recliner use or lacked access to their recliner controls. For one resident with multiple comorbidities including Alzheimer's, osteoarthritis, and congestive heart failure, there were repeated falls, including one from a recliner with the footrest elevated. Despite a high fall risk and changes in condition following hospitalization and hospice admission, the resident's care plan was not updated to reflect new transfer and supervision needs, nor were interventions for safe recliner use documented. The care plan in the electronic medical record remained outdated, and temporary paper care plans were not integrated or accessible to all staff. Another resident with severe cognitive impairment experienced a fall from bed, and although a lift chair/recliner assessment was eventually completed, the care plan did not include safety measures related to recliner use. A third resident, cognitively intact but with Parkinson's and a history of falls, fell while attempting to transfer from a recliner. Interventions identified after the fall, such as monitoring the floor for hazards, were not added to the care plan, and there were no documented interventions for safe recliner use. In all cases, the lack of timely and comprehensive care plan updates contributed to inadequate supervision and accident prevention. Staff interviews revealed inconsistent knowledge and education regarding recliner safety, with CNAs and nurses relying on personal judgment or informal communication rather than standardized protocols. Education on fall prevention was provided, but there was no documented or comprehensive education on recliner safety. Policies required care plans to address all aspects of resident care, including the use of recliners, but these were not consistently followed. Documentation systems did not allow for timely updates to care plans after falls, and staff were unclear on where to find or document recliner safety interventions, leading to gaps in supervision and accident hazard prevention.
Improper Food Labeling and Storage Leads to Expired Products
Penalty
Summary
The provider failed to properly label and store food items in the facility, leading to expired products being kept in refrigerators and coolers. Observations in two kitchenette refrigerators revealed several fruit juice cartons with expired dates. Staff interviews confirmed that the juice cartons were labeled with the date they were opened and an expiration date set for seven days later. However, some staff admitted to tasting the juice to ensure it was still good, even after the expiration date had passed. This practice was acknowledged as inappropriate by the nutrition and food service workers involved. In the main kitchen's walk-in cooler, several food items were found improperly labeled and stored. An open package of smoked cheese and a package of bacon bits were past their expiration dates, and three unopened gallons of milk were kept beyond their best-by dates. The nutrition and food supervisor admitted that the expiration date cheat sheet used by the facility was not comprehensive and that staff should have followed the expiration dates more closely. The facility's policy required opened packages to be dated and stored properly, but this was not consistently followed, leading to expired products remaining in storage.
Delayed Call Light Response Times
Penalty
Summary
The facility failed to ensure that call lights were answered promptly for a resident who used the call light to alert staff of assistance needs. Resident 29 reported waiting for over an hour on several occasions in the past few months for staff to respond to her call light. A review of the call light report from March 1 to May 30 revealed 82 instances where the response time exceeded 20 minutes, with the longest wait time being one hour and 21 minutes. Interviews with staff, including the administrator, director of nursing, and certified nursing assistant, indicated that the facility aimed to answer call lights within an average of five minutes, but the outdated call light system made it challenging to monitor response times effectively. The facility's quality assurance and performance improvement (QAPI) program included a performance improvement plan for call light times, with reports being reviewed during monthly meetings. However, the director of nursing admitted that the facility did not have a specific call light policy in place. The administrator mentioned plans to replace the call light system the following year, acknowledging the difficulties in utilizing the current system to track individual room response times. Despite these efforts, the facility's inability to promptly respond to call lights resulted in a deficiency in meeting the needs of the residents.
Infection Control Deficiencies in Glove Use and Laundry Handling
Penalty
Summary
The provider failed to ensure appropriate glove use and hand hygiene during catheter and personal care for a resident by a CNA. The CNA was observed wearing gloves while performing various tasks, including holding a pen, moving the call light, and touching sink faucets, without changing gloves or performing hand hygiene. The CNA proceeded to cleanse the resident's perineal area and buttocks with the same gloves, then handled clean items such as a brief and skin cream without changing gloves or washing hands. The CNA removed one glove, applied skin cream, and put on a new glove without washing her hands, violating the facility's infection control policy. Additionally, the provider failed to ensure that residents' clean laundry was covered during delivery to their rooms. A CNA was observed transporting laundry on an uncovered cart, exposing it to potential contamination. The CNA stated she was unaware of the requirement to cover laundry, and another CNA confirmed that covering laundry was inconsistent. The facility's infection control policy required laundry to be covered during delivery to prevent contamination.
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Illustrative
What surveyors actually found near you
We read the 21 citations issued within 25 miles in the last 12 months — including the 1 immediate-jeopardy cases — 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.
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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 Brookings
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| United Living Community | 2 mi | ★★★★★ | 9 | 0 |
| Riverview Healthcare Center | 19.8 mi | ★★★★★ | 11 | 1 |
| Flandreau Santee Sioux Tribe Care Center | 20 mi | ★★★★★ | 1 | 0 |
| Hendricks Community Hospital | 21.9 mi | ★★★★★ | 0 | 0 |
| Estelline Nursing And Care Center | 23.9 mi | ★★★★★ | 0 | 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.