Brookside Rehab: Care Plan Failed Feces-Eating Resident - VA
That gap is what inspectors found when they visited the facility on October 21, 2025.
The resident, identified in inspection records only as Resident 2, was admitted to Brookside with bipolar disorder and dementia. On a cognitive assessment completed in September 2025, she scored zero out of 15, the lowest possible score, indicating she was severely impaired in her ability to make daily decisions.
A psychiatrist who evaluated her on September 27, 2025 recorded what staff had reported: the resident had a bowel movement and was then observed playing with and eating her own feces. The note acknowledged that the timing of when the behavior started was uncertain. The psychiatrist noted no signs of anxiety, depression, delusions, or hallucinations. The behavior was documented, flagged, and then, as far as the care plan was concerned, forgotten.
The resident's comprehensive care plan, last updated November 12, 2024, contained no mention of the behavior. No interventions. No instructions for staff. No goals.
When inspectors interviewed the first certified nursing assistant assigned to the resident's wing, she said yes, she was familiar with the incidents. The resident, she explained, frequently put her hands in her pants, removed feces, and ended up with it on her hands and lips. This happened even after the resident had already been toileted. When the inspector asked whether she knew of any plan to prevent it, she said no.
The second nursing assistant told the same story. The resident frequently removed fecal material and ingested it, even after being brought to the bathroom. When she saw the resident reaching into her pants, she said, she would intervene, redirect her, or take her to the bathroom again. But a formal plan? She was not aware of one.
A licensed practical nurse on the same wing told inspectors she knew of two incidents involving the behavior and had personally witnessed one of them. After reviewing the care plan herself during the inspection, she confirmed it contained nothing about the behavior. When asked what a care plan is supposed to accomplish, she said it gives all disciplines a picture of the resident.
Nobody had written this into the picture.
Care plans are not paperwork for their own sake. They exist so that every nurse, every aide, every therapist who walks into a resident's room knows what that person needs and what risks they carry. When a resident with zero cognitive function is regularly ingesting feces, that information belongs in writing, available to anyone who might be assigned to her care for the first time on a given shift.
What the inspection found instead was a system that relied on individual nursing assistants to improvise, to notice, to intervene when they happened to be present. CNA #2 was doing exactly that, catching the behavior when she saw it and redirecting the resident. But she was doing it without any instruction, without any coordinated approach, and without any guarantee that the next person assigned to that resident would know to do the same.
The administrator, the director of nursing, the regional director of clinical operations, and a risk nurse were all informed of the findings at 3:05 p.m. on October 21, 2025. Inspectors noted that no further information was provided before they left the building.
The deficiency was rated at the lower end of the harm scale, minimal harm or potential for actual harm, and affected only this one resident in the survey sample. Brookside is a licensed nursing and rehabilitation facility at 614 Hastings Lane in Warrenton.
What the rating does not capture is what it means to be a woman who cannot speak for herself, who cannot understand what is happening to her body, and whose care team, whatever their individual attentiveness, had no written plan to protect her from a recurring, documented, dangerous behavior. The psychiatrist wrote it down in September. The care plan, dated nearly a year earlier, never caught up.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookside Rehab & Nursing Center from 2025-10-21 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: This article is based on inspection data downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases inspection reports in bulk; we publish the findings as documented by state surveyors in the official Form CMS-2567 Statement of Deficiencies.
Plan of correction: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to state survey agencies and those responses may not be reflected in CMS data at the time of publication. The absence of a plan of correction in our data does not mean one was not filed. Readers who want information about corrective steps taken are encouraged to contact the facility directly or their state survey agency.
Corrections may have occurred: Inspection reports reflect conditions observed on the date of the survey. Facilities may have implemented corrections, staffing changes, additional training, or other remediation since the report was issued. We report what CMS provides and encourage readers to seek current information from the facility.
Editorial process: Inspection findings are extracted from CMS source documents and synthesized using AI, reviewed for factual accuracy against the original report by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: September 8, 2026 · Our methodology
BROOKSIDE REHAB & NURSING CENTER in WARRENTON, VA was cited for violations during a health inspection on October 21, 2025.
That gap is what inspectors found when they visited the facility on October 21, 2025.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.