Brookview Health Care Center

Based on a review of facility policies and employee personnel files, it was determined that the facility failed to ensure that a licensure check was completed before hire for one of five employee files reviewed (Registered Nurse 1).Findings include:The facility's policy for abuse, dated February 27, 2026, indicated that potential employees would be screened for a history of abuse, neglect, exploitation, or misappropriation of resident property. Background, reference, and credential checks would be conducted on potential employees, contracted temporary staff, students affiliated with academic institutions, volunteers, and consultants.Review of the employee file for Registered Nurse 1 indicated that she was hired on December 29, 2025. There was no documented evidence that her professional license was checked to ensure it was current and that she had no disciplinary action filed.Interview with the Nursing Home Administrator on March 27, 2026, at 10:43 a.m. confirmed that they could not find any documented evidence that the licensure check was obtained prior to hire. 28 Pa. Code…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policies and clinical record reviews, as well as staff interviews, it was determined that the facility failed to provide care and treatment in accordance with professional standards of practice by failing to follow physician's orders for three of 24 residents reviewed (Residents 17, 32, 56). Findings include: The facility's policy regarding medication administration, dated April 11, 2024, revealed that medications are administered by licensed nurses, or other staff who are legally authorized to do so in this state, as ordered by the physician and in accordance with professional standards of practice, in a manner to prevent contamination or infection. An annual Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 17, dated February 5, 2025, indicated that the resident was cognitively intact, required assistance from staff for daily care needs, and had diagnosis that included dementia. Physician's orders for Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to ensure that ice was made and stored in sanitary ice machines for one of two ice machines ([NAME] House). Findings include: Observations of the ice machine in the [NAME] House pantry on February 24, 2025, at 8:16 a.m. and February 25, 2025, at 9:16 a.m. revealed that the drain pipe coming from the ice machine extended down to the floor and ran horizontally to the floor drain, resulting in no air gap between the end of the ice machine's drain pipe and the floor drain. Interview with Maintenance Worker 1 on February 25, 2025, at 9:27 a.m. confirmed that the ice machine in the [NAME] House Kitchen did not have an air gap between the drain pipe and the floor drain for back-flow prevention. 28 Pa. Code 211.6(f) Dietary Services.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to review and revise care plans for one of 24 residents reviewed (Resident 11). Findings include: The facility's policy regarding care plans, dated April 11, 2024, revealed that the comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly Minimum Data Set (MDS) assessment (a mandated assessment of a resident's abilities and care needs). A quarterly MDS assessment for Resident 11, dated January 24, 2025, revealed that the resident was understood, could usually understand others, and had a diagnosis which included Alzheimer's disease and dementia. A care plan for the resident, dated May 5, 2023, revealed that the resident was at risk for malnutrition related to his impaired mobility and dementia diagnosis. Staff was to place a non-adherent material under his plates and bowls at all meals. Observations of Resident 11 during the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of facility policies and clinical records, as well as staff interview, it was determined that the facility failed to ensure that residents were assessed and received trauma-informed care to eliminate or mitigate triggers for residents with the diagnosis of Post Traumatic Stress Disorder (PTSD - a mental and behavioral disorder that develops related to a terrifying event) for one of 24 residents reviewed (Resident 52). Findings include: The facility's policy regarding Trauma Informed Care, dated April 11, 2024, revealed that it is the policy of the facility to provide care and services which, in addition to meeting professional standards, are delivered using approaches which are culturally competent, account for experiences and preferences, and address the needs of trauma survivors by minimizing triggers and/or re-traumatization. The facility will use a multi-pronged approach to identifying a resident's history of trauma, as well as his or her cultural preferences. This will include asking the resident about triggers that may be stressors or may prompt recall of a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of clinical records, as well as staff interviews, it was determined that the facility failed to maintain a complete and accurate accounting of controlled medications (medications with the potential to be abused) for one of 24 residents reviewed (Resident 32). Findings include: A quarterly Minimum Data Set (MDS) assessment (a federally-mandated assessment of a resident's abilities and care needs) for Resident 32, dated January 24, 2025, indicated that the resident was cognitively impaired, required assistance from staff for daily care needs, had diagnosis that included dementia, and was receiving hospice services. Physician's orders for Resident 32, dated November 4, 2024, included for the resident to receive 0.25 milliliters (ml) of Morphine Sulfate Oral Solution (controlled pain medication) 20 milligrams per five milliliters (20mg/5ml) every hour as needed for breakthrough pain. Review of Resident 32's medication accountability sheet (tracks each dose of a controlled medication), dated October 19, 2024, indicated that 0.25 ml of Morphine Sulfate Oral Solution…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations and staff interviews, it was determined that the facility failed to provide a separately-locked, permanently-affixed compartment in the refrigerator for the storage of controlled drugs in the medication room at [NAME] House. Findings include: Observations in the facility's medication room refrigerator at [NAME] House on March 13, 2024, at 8:40 a.m. revealed two multi-dose bottles of Ativan (a medication used to treat anxiety that is tightly controlled because it may be abused or cause addiction) on the top shelf in the refrigerator. The refrigerator did not contain a locked compartment that was affixed to the inside of the refrigerator to secure the Ativan. Interview with Registered Nurse 1 on March 13, 2024, at 8:43 a.m. revealed that she was not aware that there was supposed to be a locked compartment affixed to the inside of refrigerator. Interview with the Director of Nursing on March 13, 2024, at 12:05 p.m. confirmed that the refrigerator should have contained a locked compartment…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of job descriptions and the deficiencies cited during the current survey, it was determined that the Nursing Home Administrator (NHA) and the Director of Nursing (DON) failed to assume responsibility for effective management of the facility to ensure that the residents' environment remained free from abuse, for ensuring that staff reported abuse and protected the resident from further abuse, and for ensuring that staff properly address a resident's behavior. Findings include: The job description for the NHA, dated January 17, 2023, indicated that the primary function of this position was to provide general oversight and direction to all services provided by the Brookview Health Care Center. Maintains compliance with the Department of Health, Welfare, Medicare, and Educational regulatory requirements. Supervision and coordination of services to include overseeing budget and corporate policies and procedures related to the care of all residents. The job description for the DON, dated October 15, 2020, indicated that the primary function of this position was to…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on clinical record reviews and staff interviews, it was determined that the facility failed to ensure that a baseline care plan included instructions regarding behaviors and the use of psychotropic medications for one of five residents reviewed (Resident 5) who was admitted after February 9, 2024. Findings include: A nursing note, dated February 9, 2024, at 11:14 a.m., revealed that the resident was admitted to the facility on this date. Physician's orders, dated February 9, 2024, included orders for 12.5 mg of Seroquel in the morning and 25 mg of Seroquel(antipsychotic) at bedtime for dementia with behaviors, 0.25 milliliters (mL) of lorazepam (anti-anxiety) three times a day for anxiety, and 10 mg of escitalopram (anti-depressant) in the morning for major depression. A Certified Registered Nurse Practitioner (CRNP, a registered nurse who has advanced education and clinical training in a health care specialty area) note, dated February 9, 2024, revealed that the resident was agitated and anxious, refused to have her dressing changed, refused to have a skin evaluation, and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on review of policies and clinical records, as well as staff interviews, it was determined that the facility failed to develop comprehensive care plans that included specific and individualized interventions to address resident care needs for one of five residents reviewed (Resident 2). Findings include: The facility's policy regarding behaviors, dated April 13, 2023, revealed that facility staff will attempt to implement person-centered care approaches designed to meet the individual goals and needs of each resident, which includes non-pharmacological interventions. An admission Minimum Data Set (MDS) assessment (a mandatory assessment of a resident's abilities and care needs) for Resident 2, dated November 16, 2023, revealed that the resident was understood, understands, and had a diagnosis which included Parkinson's disease, anxiety, and depression. A nursing note for Resident 2, dated January 18, 2024, revealed that the nurse and the nurse aide attempted to get the resident into the bath multiple times. The resident refused and became combative and kept stating she will…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.