Brooke Grove Rehab. & Nsg Ctr
BROOKE GROVE REHAB. & NSG CTR in SANDY SPRING, MD — inspection on March 30, 2026.
Found 2 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Review of Resident #7's October 2025 and November 2025 Medication Administration Records (MAR) documented that Resident #7 received Tylenol on 10/31/25 at 9:30 PM, which was within the 5 day look back window.
Review of the significant change MDS, Section J0100 prn (when needed) pain, failed to capture the use of Tylenol.On 3/27/26 at 1:22 PM an interview was conducted with MDS staff #5.
The progress notes and the change in condition note for the fall along with the use of Tylenol were reviewed. On 3/27/26 at 2:30 PM MDS staff #5 confirmed the errors.2) On 3/27/26 at 1:00 PM a review of Resident #8's medical record was conducted and revealed a quarterly MDS with an assessment reference date of 10/15/25 which documented in Section N0415 (High-Risk Drug Classes) the use of an Opioid medication.
Opioid medications are powerful prescription drugs used to treat moderate to severe pain that have a high potential for addiction.Review of Resident #8's October 2025 MAR failed to produce documentation that Resident #8 was prescribed an Opioid. On 3/30/26 at 10:19 AM an interview was conducted with MDS Director #8 who confirmed the error.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided.
For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER TITLE (X6) DATE REPRESENTATIVE'S SIGNATURE
215200 03/30/2026
Brooke Grove Rehab. & Nsg Ctr 18131 Slade School Road Sandy Spring, MD 20860
Review of Resident #2's medical record on 3/26/26 revealed the Resident was admitted to the facility in March 2026, had a fall on 3/6/26 and was sent to the hospital on 3/9/26.
Review of Resident #2's March 2026 Medication Administration Record revealed the Resident received Tramadol 25 mg on March 8th, 2026 at 9:23 AM.
Tramadol is a narcotic pain medication used to treat moderate to severe pain.
Review of Resident #2's Controlled Drug Receipt/Record/Disposition Form that is not kept in the Resident's medical record but on the nurse's medication cart revealed the Resident received Tramadol 25 mg on 3/8/26 at 11 AM, 3/8/26 at 9:00 PM and 3/9/26 at 9 AM.
During interview with the Director of Nursing (DON) on 3/30/26 at 10:40 AM, the DON stated it is the expectation that the facility staff will document the administration of narcotics on a resident's medication administration record.
Interview with Director of Nursing on 3/30/26 at 2:15 PM confirmed between 3/8 and 3/9/26 the Resident received 3 doses of Tramadol according to the Resident's Controlled Drug Receipt/Record/Disposition Form but only 1 dose is recorded the Resident's March 2026 Medication Administration Record.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SANDY SPRING, MD, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BROOKE GROVE REHAB. & NSG CTR or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.