The Villas at Brookview

Inspectors wroteBased on interview and document review, the facility failed to ensure a developed skin rash was assessed and treatment initiated timely to promote healing for 1 of 4 residents (R4) reviewed for non-pressure skin conditions.

Inspectors wroteBased on observation, interview, and document review, the facility failed to consistently track and monitor dishwasher temperatures for both the wash and rinse cycles, and take timely action to correct the temperatures, for 1 of 1 dishwasher observed. This had the potential to affect all current residents, as well as staff or visitors, who ate food served from dishes and tableware that were cleaned in the dishwasher. Additionally, the facility failed to ensure food items were properly labeled, dated, and stored in the walk-in freezer. The facility also failed to assure that proper hair and beard restraints were used by staff members preparing food within the kitchen. These factors had the potential to impact all residents, staff, and visitors who received food from the kitchen.

Inspectors wroteBased on documentation and interview, the facility failed to ensure residents were informed of and consented to medications prescribed and given for mental health intervention for 1 of 5 residents (R53) review for unnecessary medication review.

Inspectors wroteBased on observation, document review, and interview, the facility failed to comprehensively assess residents scoring high on a PHQ-9 (an assessment to determine someone's depression) for 1 of 1 resident (R53) in the samplewho displayed signs and symptoms of moderate depression.

Inspectors wroteBased on interview and document review the facility failed to request a screening in follow up for a new diagnosis of mental illness identified after admission for 1 of 1 resident (R12) reviewed for Preadmission Screening and Resident Review (PASRR).

Inspectors wroteBased on observation, interview, and document review, the facility failed to coordinate services for 1 of 1 resident (R56) evaluated for hospice services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to ensure residents were free of medication errors of less than 5% for 1 of 3 residents (R66) observed for medication administration resulting in an 8% error rate.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate medical records for 1 of 1 resident (R13) reviewed for mental health practitioner visits.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement proper precautions for 2 of 3 residents (R16, R64) reviewed for contact precautions.

Inspectors wroteDuring interview and record review, the facility failed to ensure all residents were offered and up to date on immunizations for 2 of 5 residents (R60, R69) reviewed for immunizations.

Inspectors wroteBased on interview and record review, the facility failed to report potential neglect (the failure of the facility, it's employees of service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional stress) to the State Agency (SA), no later than 24 hours for 1 of 3 (R1) residents reviewed for reporting. R1 was given insulin at the incorrect time without a provider's order. R1 was sent to the hospital later that day for hypoglycemia (low blood glucose which includes dizziness, fatigue, sweating, and confusion).

Inspectors wroteBased on interview and record review, the facility failed to initiate an investigation for potential neglect (the failure of the facility, it's employees of service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish or emotional stress) for 1 of 3 residents (R1) reviewed for investigation, prevention and correction of alleged allegation. R1 was given insulin at the incorrect time without a provider's order. R1 was sent to the hospital later that day for hypoglycemia (low blood glucose which includes dizziness, fatigue, sweating, and confusion).

Inspectors wroteBased on observation, interview, and record review the facility failed to prevent a significant medication error for 1 of 3 residents reviewed for medication errors. R1's Aspart (a short acting insulin) was given at the incorrect time. The Aspart insulin was ordered as an insulin sliding scale (an order in which the insulin dose is based on a resident's blood glucose level) to be taken with meals and was given at 2:15 p.m. without a meal. In addition, during the survey process R1's 8:00 a.m. medications were administered nearly three hours late.

Inspectors wroteBased on interview and record review the facility failed to maintain accurate medical records for 1 of 3 residents (R1) reviewed for resident records. R1's medication administration was inaccurately documented when R1's medication Aspart (fast acting insulin) was only administered on 3/13/26 at 2:15 p.m. R1's electronic medical record (eMAR) indicated R1's Aspart insulin was administered on 3/13/26 at 12:00 p.m. and 5:00 p.m.

Inspectors wroteBased on observations, interviews, and document review, the facility failed to ensure medications were stored securely in areas where residents, staff and guests could not access medications in 1 of 1 medication carts observed, potentially affecting one unit, Unit 400, of the facility.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a baseline care plan to properly care for 1 of 3 residents (R2) reviewed for baseline care plan. Additionally, the facility failed to provide a summary of the baseline care plan to 1 of 3 residents (R2).

Inspectors wroteBased on interviews, observation, and document review the facility failed to comprehensively develop and implement care plan interventions for 1 of 3 residents (R4) when R4 had poor nutritional intake with a diagnosis of malnutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pressure ulcer prevention interventions were utilized as ordered for residents at risk of developing pressure ulcers for 2 of 3 residents (R1, R4) reviewed who were at risk for pressure ulcers.

Inspectors wroteBased on interview and document review, the facility failed to provide safe transfers for 1 of 3 residents (R5) when one staff transferred R5 with an EZ Stand (mechanical lift used to move a person who can bear weight from one surface to another) but required assistance of two staff with an EZ Stand for safe transfers.

Inspectors wroteBased on interview and document review the facility failed to sufficiently manage pain or offer non-medication pain management interventions for 1 of 3 residents (R2) reviewed for pain management. R2's admission Data Collection (nursing assessment) dated 2/16/26 at 12:50 p.m., indicated R2 had pain frequently over the past five days that made it hard to sleep at night, limited day-to-day activities, and affected sleep, rated as moderate pain at five (5) on a scale of 0-10. R2 received scheduled and as needed (PRN) pain medication and non-medicine interventions to relieve pain. R2's Physical Therapy (PT) Evaluation and Plan of Treatment dated 2/17/26, (no time) indicated R2 had pain that interfered with functional activity and sleep, and nursing would address the pain. [...]

Inspectors wroteBased on interview and document review, the facility failed to ensure nurses were timely and competently trained on medication administration for 1 of 3 residents (R1) reviewed with specific orders for administration of oral medication.

Inspectors wroteBased on interview and document review, the facility failed to ensure 1 of 3 residents (R3) was free from a significant medication error. This resulted in an Immediate Jeopardy (IJ) for R3 who was given the wrong dose of medication that resulted in hospitalization in the intensive care unit. The IJ began on 11/4/25 at 7:07 a.m. when R3 was administered the incorrect amount of 40 milligrams (mg) of methadone (a long-acting opioid pain medication) which was 16 times the prescribed amount of 2.5 mg. The administrator and director of nursing (DON) were notified of the IJ on 11/7/2025 at 1:50 p.m. The IJ was removed on 11/5/25 prior to the start of the survey and was therefore past noncompliance

Inspectors wroteBased on observation, interview, and record review the facility failed revise the fall care plan to include individualized intervention (fall mat) for 1 of 3 residents (R4), who was reviewed for quality of care/treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were comprehensively assessed for self-administration of medications for 1 of 1 resident (R27) reviewed for self-administration of medication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nursing rehabilitation services were provided for 1 of 1 residents (R7) who was care planned for passive range of motion (ROM).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nail care was completed for 1 of 2 residents (R27) who were reviewed for being dependent on staff for activities of daily living (ADLs).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure skin abrasions were adequately assessed and monitored for 1 of 1 resident (R27) reviewed for non-pressure related skin concerns.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure recommended dental services were provided for 1 of 2 residents (R13) reviewed for dental services.

Inspectors wroteBased on observation, interview, and document review, the facility failed to notify a resident's physician of the deterioration of a non-pressure related skin wound for 1 of 3 residents (R3) reviewed for non-pressure related skin wounds.

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure professional standards of practice for treatment orders were followed for 2 of 3 residents (R1, R2) reviewed for non-pressure related skin wounds who had wound care orders which were not transcribed.

Inspectors wroteBased on observation, interview, and document review, the facility failed to comprehensively assess non-pressure related skin wounds for 2 of 3 residents (R1, R2) reviewed for non-pressure related skin wounds. In addition, the facility failed to administer non-pressure related skin wound treatments in accordance with physician orders for 1 of 3 residents (R1) and failed to identify deterioration of a non-pressure related skin wound for 1 of 3 residents (R3) reviewed for non-pressure related skin wounds.

Inspectors wroteBased on interview and document review, the facility failed to maintain complete, accurate, and up-to-date medical records of administered wound care treatments for 1 of 3 residents (R1) reviewed for non-pressure related skin injuries.

Inspectors wroteBased on interview and record review the facility failed to develop and implement discharge plans that addressed all the needs for 1 of 3 (R2) residents reviewed for discharge. R2 was discharged before a waiver evaluation was completed at the facility resulting in discharging to home without a personal care assistant (PCA). In addition, incorrect orders were transcribed as R2 was ordered to have a skilled nurse (SN) from the home care agency, the facility ordered a home health aide instead and R2's medications and dialysis were not ordered correctly.

Inspectors wroteBased on interview and document review the agency failed to maintain current certification for the Clinical Laboratory Improvement Amendments (CLIA) waiver, which is required for agencies performing blood testing. This had the potential to affect patients who received blood testing by the agency, including those residents who had received routine glucose testing (check of blood sugar). This included R9, R10, R11, R12, R13, R14, R15, R16, R17, R18, R19, R20, R21, R22, R23, R24, R25, R26, R27, R28, R29, R30, R31, R32, R33, R34, and R35. On [DATE], at 10:00 a.m. a review of the facility certifications was completed upon entrance to the facility. At this time, a document dated [DATE], indicated the CLIA waiver became effective [DATE] and expired on [DATE]. On [DATE], at 2:00 p.m. [...]

Inspectors wroteBased on observation, interview and document review, the facility failed to ensure physician orders were followed to promote good nutritional intake for 1 of 1 residents, (R1), with the diagnoses of end stage renal disease and diabetes.

Inspectors wroteBased observation, interview and document review, the facility failed to ensure community use glucometer were properly cleaned and disinfected between resident use for 1 of 2 glucometers on the second floor.