Neighborhoods at Brookview: Safety Hazard Pattern - SD
The November 2025 complaint inspection at The Neighborhoods at Brookview flagged violations under the fall prevention and restraint use standards, affecting some residents. The level of harm was cited as minimal or potential, but the gap between what the facility committed to on paper and what inspectors found in practice ran through multiple policies at once.
The facility's own fall prevention policy, last updated in August 2022, required staff to conduct a nursing assessment after every fall, identify possible causes, note the fall in the care plan, seek team input, and update the care plan as needed. Inspectors found those steps weren't consistently happening.
The restraint policy, updated in July 2025, explicitly listed lift chairs and recliners among examples of nontraditional restraints, specifically because placing a resident in one can prevent them from rising on their own. A policy issued just two weeks before the inspection, on October 30, 2025, required an assessment before using those chairs and said the use had to be addressed in each resident's care plan.
The timing matters. A policy written fourteen days before inspectors arrived still wasn't being applied.
Lift chairs are common in memory care and assisted living settings, often seen as comfort furniture rather than a safety intervention. But for a resident who cannot get up without help, the chair functions as a restraint, and the facility's own documents acknowledged that. The assessment and care planning requirements exist precisely because of what happens when that distinction gets ignored: residents can be held in place without any formal review of whether it's appropriate, necessary, or safe.
The inspection did not name individual residents. What it documented was a facility that wrote the right policies and then didn't follow them, including one it had just finished writing.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for The Neighborhoods At Brookview from 2025-11-13 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: August 4, 2026 · Our methodology
THE NEIGHBORHOODS AT BROOKVIEW in BROOKINGS, SD was cited for violations during a health inspection on November 13, 2025.
Inspectors found those steps weren't consistently happening.
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.