Brookfield Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure one of five sampled residents (Resident 19) was free of significant medication errors, when:1. Resident 19's orders for Percocet (medication used to treat moderate or severe pain) and methocarbamol (a muscle relaxer used to relieve muscle, bone, and joint pain) were not clarified.2. Resident 19 was administered methocarbamol and Percocet together. These deficient practices had the potential to result in Resident 19 experiencing sedation (when given too much a medication that makes an individual sleepier or less conscious than intended) and respiratory arrest (when an individual stops breathing).

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan with interventions for two of eight sampled residents (Resident 19 and 48) to address:1. Resident 19's use of methocarbamol (a muscle relaxer used to relieve muscle, bone, and joint pain).2. Resident 48's lack of dentures (a removable dental appliance that replaces missing teeth and surrounding tissues). This deficient practice had the potential to negatively affect Resident 19 and 48's mental, physical, and psychosocial well-being and had the potential to delay the delivery of necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to implement fall prevention interventions for one of three sampled residents (Resident 1) when staff failed to:1. Complete all sections of Resident 1's Fall Risk Evaluation, and develop a short-term fall care plan, following his fall on 11/13/2025.2. Conduct a Fall Risk Evaluation after Resident 1's fall on 11/21/2025.3. Revise Resident 1's fall risk care plan following his falls on 11/13/2025 and 11/21/2025. These deficient practices placed Resident 1 at risk for repeat falls and potential injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure oxygen therapy (a medical treatment that provides extra oxygen to breathe, typically prescribed for individuals with conditions causing low blood oxygen levels) was administered as ordered by the physician for two of 18 sampled residents (Residents 72 and 19). This deficient practice placed Resident 72 and Resident 19 at risk of sustaining complications of receiving too much supplemental oxygen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a meal that was attractively appeasing and palatable for one of two sampled residents (Resident 71). This deficient practice had the potential for Resident 71's individual dietary and nutritional needs not being met, causing Resident 71 to not want to eat.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain infection control measures for one of five sampled residents (Resident 61) when:1. Resident 61 was placed on contact precautions (using extra barriers, like gowns and gloves, to stop germs from spreading by touching a sick person or things in their room) with no visual signage to ensure hands were washed with soap and water. 2. Licensed Vocational Nurse (LVN) 2 performed hand hygiene with alcohol-based hand rub (ABHR- a liquid that is rubbed on the hands to quickly kill germs and stop their spread, without needing soap and water) instead of soap and water upon exiting Resident 61's room. These deficient practices had the potential to result in the spread of clostridium difficile (C. diff- a highly contagious bacteria that causes severe diarrhea) to the residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to conduct an accurate fall reassessment for one of seventeen residents (Resident 3), after a fall. This deficient practice had the potential for Resident 3 not to receive the proper interventions to prevent further falls and injuries.

Inspectors wroteBased on interview and record review, the facility failed to develop a resident-centered plan of care after one of three sampled residents (Resident 3), had a fall. This deficient practice resulted in the facility not having a care plan to implement for the resident's safety after the fall and had the potential to cause recurrent falls.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three sampled residents (Residents 30) would not be administered any unnecessary medication in the form of duplicate drug therapy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a complete informed consent form (voluntary agreement to accept treatment and/or procedures after receiving education regarding the risks, benefits, and alternatives offered) included the medication dosage, frequency, and behavioral manifestations prior to the administration of citalopram (medication used to treat major depressive disorder [a mood disorder that causes a persistent feeling of sadness and loss of interest]) for one of five sampled residents (Resident 32). This deficient practice had the potential to result in Resident 32 and their Responsible Party (RP) being unaware of the medication treatment ordered, thus, being unable to make an informed decision regarding Resident 32's care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment entries on the Minimum Data Set ([MDS], a federally mandated resident assessment tool) were accurate for four of six sampled residents (Residents 3, 9, 32, and 253) when the facility failed to: 1. Include a diagnosis of depression (a mood disorder that causes a persistent feeling of sadness and loss of interest) per information in Resident 32 and Resident 3's medical record. 2. Include Resident 9's five (5) percent (%) weight loss in one month. 3. Include a diagnosis of seizure disorder (a disorder where a sudden, uncontrolled electrical disturbance in the brain which can cause uncontrolled jerking, blank stares, and loss of consciousness) per information in Resident 253's medical record. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a person-centered care plan (document that helps nurses and other team care members organize aspects of resident care) with interventions (actions a nurse takes to implement a care plan, intend to improve the resident's comfort and health) in a timely manner for three out of six sampled residents (Resident 153, Resident 42, and Resident 21) when the facility failed to ensure the following: 1. Ensure a care plan was developed after the discovery of Resident 153's cancer of the left eye and skin. 2. Ensure a care plan was developed for Resident 42's use of a nicotine patch (a patch worn on the skin by a person trying to give up smoking). 3. [...]

Inspectors wroteBased on interview and record review, the licensed nurses failed to review, update, and/or revise a care plan (written document developed for each individual by the support team using a person-centered approach that describes the supports, services, and resources provided or accessed to address the needs of the individual) to reflect the attempts to prevent future falls for one out of one sampled resident (Resident 21). This deficient practice resulted in the facility having no interventions in the prevention for further falls for Resident 21 and could have potentially led to Resident 21's third fall.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an interdisciplinary team (IDT, group of different disciplines working together towards a common goal of a resident) meeting was held after a resident fall on 9/16/2024 for one of one sampled resident (Resident 21). This deficient practice delayed the plan of care for reducing the risk of falls and could potentially have caused Resident 21 to sustain another subsequent fall.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two of 12 sampled residents (Residents 253 and 21) were free of accidents and hazards by failing to: 1. Ensure floor mats (a cushioned floor pad designed to help prevent injury should a person fall) were utilized for Resident 253. 2. Ensure Resident 21 had an interdisciplinary team ([IDT], a group of healthcare professionals with various areas of expertise who work together towards the goals of the residents) review after a fall on 9/16/2024. These deficient practices had the potential to result in Resident 253 sustaining injuries during a seizure (a disorder in which nerve cell activity in the brain is disturbed) by potentially falling and hitting his head or other body parts on the bare floor. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nursing staff practiced safe and effective medication administration practices for four out of five sampled residents (Resident 19, 25, 48, and 49) when: 1. Registered Nurse (RN 2) did not administer medication to Resident 19 in a timely manner. 2. RN 3 left Resident 25's medications at the resident's bedside to self-administer. 3. Licensed Vocational Nurse (LVN) 2 did not administer medication to Resident 25 in a timely manner. 4. LVN 2 did not administer medication to Resident 48 in a timely manner. 5. LVN 1 signed the medication administration audit report for Resident 49 after another LVN administered pain medication. [...]

Inspectors wroteBased on interview and record review, the facility failed to identify a drug irregularity (any deviation in the proper use, dosage, or administration of medication) during the Monthly Regimen Review (MRR - a regular assessment of a resident's medication and treatment plan every month to ensure it is effective, safe, and still necessary) for one of three residents (Resident 30) receiving duplicate drug therapy in the use of two orally inhaled medications, Serevent Diskus (salmeterol, a long-acting bronchodilator used to treat asthma by relaxing and opening air passages in the lungs, making it easier to breathe) and Advair Diskus (a medication that contains both salmeterol and fluticasone propionate, an anti-inflammatory medicine, used to treat asthma and chronic obstructive pulmonary disease (COPD - lung disease that makes it difficult to breathe) between 9/13/2024 through 10/15/2024. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure opened boxes of oral inhalation medications with a shortened expiration date once opened, had an open date (the date the medication was first opened) for three of three sampled residents (Resident 30, Resident 53, and Resident 54). The deficient practice of failing to label oral inhalation medications, per the manufacturers' requirements increased the risk that residents with asthma (chronic inflammatory disease of the lungs) or chronic obstructive pulmonary disease (COPD - a chronic lung disease causing difficulty in breathing) could have received expired or ineffective medications which could result in health complications, difficulty breathing, or hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure one of three residents' (Resident 1) itchy area was assessed, location/ site identified and ensure the physician's order contained the site of treatment order administration. This failure had the potential for Resident 1's skin itchiness not resolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement interventions to prevent a fall with injury for one of three residents (Resident 19) with history of falls by failing to: 1. Ensure Resident 19 performed toilet transfers toward the left, unaffected side and did not place weight onto the right leg after toileting. 2. Provide Resident 19 with two-persons assistance for toilet transfers and toilet hygiene (toileting, includes managing undergarments, clothing, and incontinence products and performing cleansing before or after voiding or having a bowel movement). 3. Provide Resident 19 with two-persons assistance for sit to stand transfers (transfers from a seated position to a standing position) after toileting. These failures resulted in Resident 19 falling from a standing position onto the floor in the restroom on 7/30/2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer Folic Acid (a medication used as a supplement for heart health) 1 mg tablet as ordered by the physician for one of four sampled residents during medication administration (Resident 28) and failed to administer Norco (a brand name for hydrocodone-acetaminophen, a combination medication used to treat pain) on time for one of five sampled residents (Resident 21.) As a result, Residents 21 and 28 did not receive medication in accordance with the physician's orders and standards of practice and had the potential to experience adverse effects (unwanted effects from a medication) and negative impact to their health and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Margarine was observed at 74 Degrees (º) Fahrenheit (F). b. The ice machine baffle (slanted component used to keep ice from falling out of the bin when the door is opened) was observed with black and pink residues. c. The storage areas for the pots and pans were observed with dust and dirt residue. d. The mixer attachments were found with oil residue. e. Seven (7) resident's food trays were observed chipped and cracked. f. The refrigerator shelves were observed chipped with black and orange metal discoloration exposed. g. The trayline area was observed with black, reddish dirt and grease build up. h. One expired resident yogurt in the resident's refrigerator. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain equipment in safe operating condition in the kitchen and the rehabilitation room by failing to: a. Maintain the kitchen refrigerator by the preparation area in a safe operating condition. b. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a code status (the type of emergent treatment a person would or would not receive if their heart or breathing were to stop) was ordered and an Advance Directive (a written statement of a person's wishes regarding medical treatment, made to ensure those wishes are carried out should the person be unable to communicate them to a doctor) was readily available to facility staff for one of three sampled residents (Resident 2) This failure had the potential for harm to Resident 2 as staff and emergency medical personnel would perform life-sustaining measures in the event of an emergency, which did not align with the wishes expressed and documented by Resident 2 and her family.

Inspectors wroteBased on interview and record review, the facility failed to ensure the responsible party (RP) for one of three sampled residents (Resident 11) was appropriately notified regarding changes to Resident 11's Medicare coverage through provision of the Notice of Medicare Non-Coverage (NOMNC) form and the Skilled Nursing Facility Advance Beneficiary Notice of Non-Coverage (SNFABN) form. This deficient practice had the potential to result in Resident 11, or Resident 11's RP, not being able to exercise their right to file an appeal and to unknowingly paying for non-covered care expenses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to effectively manage a resident's pain for one of five sampled residents (Resident 21). This failure caused Resident 21 to endure pain for almost three (3) hours before being treated with pain medication.