Not rated by CMS — ratings are suppressed for new or low-volume facilities.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookview Healthcare Center during CMS and state inspections, most recent first.
A resident with dementia and a history of exit-seeking behavior was able to leave the facility unsupervised due to inadequate staff supervision, ineffective communication during shift change, and insufficiently audible door alarms. The resident was found over a mile away by a staff member and returned without injury. Staff interviews and observations revealed inconsistent rounding practices and that the exit door alarm was not always loud enough to alert staff.
A resident with cognitive impairment wandered into another resident's room and was found naked on top of them, leading to a failure to protect the resident from sexual abuse. Staff intervened but did not report the incident as a potential sexual assault, and the resident's family was not promptly notified. The facility's inadequate response and lack of proper reporting procedures contributed to the deficiency.
A facility failed to report an alleged sexual abuse incident involving two residents with dementia. A resident was found naked on top of another resident, but staff did not report the incident to the SSA, believing there was no evidence of assault. The incident was later reported by the resident's family to the Ombudsman. The facility's policy requires such incidents to be reported immediately, but this was not followed.
A resident with anxiety and dementia successfully eloped from a facility due to inadequate supervision and potential door alarm issues. Despite having no prior elopement risk factors, the resident left after becoming upset over a dress dispute. The resident was found by police with bruises after obtaining a ride from college students. Staff interviews revealed a failure in supervision and monitoring, highlighting issues with the facility's elopement response and door alarms.
The facility failed to maintain proper food storage temperatures, with observations revealing malfunctioning refrigerators and freezers, expired and improperly labeled food items, and incomplete temperature logs. Residents reported dissatisfaction with food quality, and staff interviews highlighted inconsistencies in temperature monitoring.
The facility did not have an RN on duty for 8 consecutive hours on several occasions, as confirmed by schedule reviews and interviews with the DON and Staffing Coordinator. The facility lacks a specific staffing policy, relying on federal regulations.
The facility was found deficient for not having a policy on handling and monitoring outside food brought in by visitors. Interviews with the Dietary Manager and Administrator confirmed the absence of such a policy, highlighting a gap in the facility's operational procedures.
The facility failed to prevent the misappropriation of medications for two residents, who reported not receiving their prescribed Hydrocodone-acetaminophen. Record reviews showed discrepancies in the Controlled Drug Record and missing documentation in the Medication Administration Record. The DON acknowledged irregularities in the medication sign-out process.
Failure to Prevent Elopement Due to Inadequate Supervision and Ineffective Door Alarms
Penalty
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.
Failure to Protect Resident from Sexual Abuse
Penalty
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.
Failure to Report Alleged Sexual Abuse Incident
Penalty
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.
Resident Elopement Due to Inadequate Supervision
Penalty
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.
Improper Food Storage and Temperature Monitoring
Penalty
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.
Failure to Maintain RN Staffing for Required Hours
Penalty
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.
Lack of Policy for Handling Outside Food
Penalty
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.
Misappropriation of Medications for Two Residents
Penalty
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.
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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 Gaffney
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Peachtree Centre | 2.4 mi | — | 0 | 0 |
| Palmetto Patriots | 2.8 mi | — | 0 | 0 |
| Skylyn Nursing And Rehabilitation Center | 6.5 mi | — | 0 | 0 |
| White Oak Estates | 13.6 mi | — | 2 | 0 |
| Summit Hills Skilled Nursing Facility | 14.4 mi | — | 4 | 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 August 2026) and official state health department websites.