Life Care Center of Brookfield

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of three sampled residents, was free from significant medication error. Staff administered Resident #1 another resident's (Resident #3's) 8:00 A.M. scheduled medications\and then following the error, administered Resident #1's scheduled 8:00 A.M. medications. Resident #1 experienced low blood pressure, lethargy, increased weakness, and required intravenous (IV) fluids. The facility census was 78. Review of the facility policy Administration of Medications, dated 9/16/24, showed the following: -The facility would ensure medications are administered safely and appropriately per physician order to address residents' diagnoses and signs and symptoms; -Significant medication error meant one which caused the resident discomfort or jeopardized his/her health and safety. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure ice machines were free of a buildup of black debris, were equipped with an appropriate air gap and had clean water filters, failed to ensure food items were not stored directly on the floor, failed to ensure food items were closed or sealed properly after use, and failed to ensure a ceiling vent was free of a buildup of debris. The facility census was 89. 1. Review of the facility policy, Ice Machines, revised 6/12/23 showed ice machines should be maintained in a clean and sanitary state following infection prevention and control guidelines. Review of the facility policy, Preventative Maintenance-Ice Machines, revised 1/11/23 showed all ice machines in the facility will be inspected by the in-house maintenance department on a monthly basis and the coils will be cleaned every quarter. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care in a manner to prevent the development and transmission of diseases and infections for four residents (Residents #41, #55, #293, and #22), in a review of 20 sampled residents, and three additional residents (Resident #30, #80 and #294). Staff failed to utilize Enhanced Barrier Precautions (an infection control intervention that utilizes personal protective equipment to reduce the spread of multi drug-resistant organisms) during personal care for one resident (Resident #55), who had a tracheostomy (an incision in the windpipe made to relieve an obstruction to breathing) tube and a feeding tube (tube inserted into the stomach for nutrition); failed to utilize proper handwashing and gloving when providing incontinence care to one resident (Resident #22); [...]

Inspectors wroteBased on interview and record review of a sample of seven residents, the facility failed to ensure one resident (Resident #6 ), received care according to professional standards when staff failed to obtain and administer medications per physician's orders upon admission for Resident #6, with a tracheostomy (surgical opening into the trachea or windpipe from outside the neck which allows breathing through a tube inserted into the opening), including breathing treatments, injectable medication to prevent blood clots, and medications to stimulate the resident to stay awake. The facility also failed to ensure the resident received the prescribed dosage of heart failure medication and cholesterol medication. The resident developed severe respiratory issues and required emergent treatment in the hospital. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly assess one bed-bound bariatric resident (Resident #38), in a review of 20 sampled residents, to ensure the facility maintained the proper equipment to safely transfer the resident from his/her bed, and failed to ensure their policy and the resident's plan of care related to emergency evacuation procedures for a bariatric resident would be successful as they had not identified the number of staff required or the equipment necessary to safely evacuate the resident from the facility. The facility did not know the resident's current weight and could not determine if the transfer equipment available could meet the resident's weight requirement in order to safely transfer the resident without injury. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to meet residents' needs in the event of an emergency when the facility was unsure how many staff it would require to safely evacuate one morbidly obese resident (Resident #38) of 60 sampled residents. The facility identified 23 residents that required mechanical lift transfers, 15 that required the assist of two staff and 22 that required staff stand-by assist to evacuate. Facility staff failed to ensure their policy for getting bariatric residents to safety in the event of an emergency would be successful as they had not practiced the plan. Some staff identified six staff would be enough to get Resident #1 to safety. Review of the staffing for 11:00 P.M. to 4:30 A.M. showed only six staff available, leaving no staff to ensure the safety of the other residents. The facility census was 92. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one resident (Resident #38) in a sample of 20 residents, who presented with diagnoses of bipolar and depression and who has a history of past traumatic events, including abuse and suicide attempts, received the necessary behavioral health care services to maintain the highest practicable physical, mental and psychosocial well-being. The facility failed to obtain the resident's level II screening completed in 2016. The facility also failed to obtain a level II screening when the resident had a change in behavior and status. Staff have not been educated regarding behaviors or mental illness and did not identify behavioral triggers or past traumatic experiences that affected the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to failed to provide a wheelchair and a lift sling to accommodate one resident (Resident #38) and failed to ensure call lights were in reach for three residents (Resident #28, #63, and #147), in a review of 20 sampled residents. Resident #38 was unable to transfer from his/her bed as the sling used with the facility's mechanical lift caused severe pain, cutting into his/her legs. Additionally, the facility did not have a wheelchair that fit the resident's physical needs. As a result, the resident's movements were restricted to his/her room for over two years, contributing to the resident feeling depressed and unsafe. The facility census was 92. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #38), a resident with a past history of abuse and diagnoses including post traumatic stress disorder and depression, in a review of twenty sampled residents, was free from mental and emotional abuse. The resident was totally dependent on staff and was bed bound as a result of facility failure to ensure he/she had appropriate transfer equipment. The resident had not been able to leave his/her room in at least two years and participate in any activity outside of his/her room. The resident was alert and oriented. The resident reported staff were mean and hateful in their interactions with him/her, he/she felt ignored and an inconvenience for staff. Staff accused him/her of crying wolf and wasting his/her body. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident (Resident #28), of 20 sampled residents, had a nutritional assessment completed on admission, received weights per facility protocol, and failed to ensure his/her feeding tube was connected as ordered for continuous feeding to ensure he/she received adequate nutrition. The resident had a 9.5 pound (-7.68%) weight loss in ten days. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents on a physician-ordered pureed diet received the appropriate portion size of food items and failed to ensure spreadsheet menus were utilized for all diets to ensure appropriate items and portion sizes were prepared and served. The facility census was 92. Review of the undated facility policy, Tools for Food Preparation, showed the following: -The menu is the primary tool used in food preparation; -It specifies the foods that are to be served on both the regular and therapeutic diets; -It specifies the portion sizes to be served. Review of the undated facility policy, Portioning and Measuring Utensils, showed all items must be measured during preparation and during serving according to recipes and the menu. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure sanitary practices in the kitchen. The census was 92. Review of the undated facility policy, Prevention of Foodborne Illness, showed the following: -To ensure that we prepare and serve safe food to our residents, we must consistently practice habits that help prevent foodborne illnesses. These practices must become a way of life in our department; -Avoid scratching, picking or rubbing your head, nose, face, or body surface. If you do so, wash your hands afterward; -Wash your hands after handling soiled dishes or utensils and before handling unwrapped flatware or clean equipment and utensils; -Wash raw vegetables thoroughly, and then wash your hands after washing the vegetables; -Store food in enclosed containers; -Label and date all food appropriately; -Keep equipment clean and in good repair; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop specific control parameters based on Center for Disease Control (CDC) and American Society of Heating, Refrigerating, and Air Conditioning Engineers (ASHRAE) standards and failed to complete a facility assessment. The facility did not have a water management team, detailed water flow map, and did not implement the facility's Legionnaire Disease (severe pneumonia like infection caused by contaminated water) policy that instructed staff how to monitor residents for Legionnaire's disease. The facility also failed to ensure staff performed proper hand hygiene when caring for residents when staff failed to wash hands and change gloves during a blood sugar check and food preparation for one resident (Resident #50). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat six residents with dignity (Resident #44, #62, #147, #90, #35 and #83), in a review of 26 sampled residents. The facility census was 92. Review of the facility policy, Dignity, reviewed 9/30/22, showed each resident has the right to be treated with dignity and respect. Interactions and activities with residents by staff, temporary agency staff, or volunteers must focus on maintaining and enhancing the resident's self-esteem, self-worth, and incorporating the resident's goals, preferences, and choices. Staff must respect the resident's individuality as well as, honor and value their input. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to create an environment respectful of the rights of each resident to make choices about significant aspects of their lives for two residents (Residents #8 and #9) in a review of 14 sampled residents and six additional residents (Residents #21, #18, #16, #19, #17 and #20), who all had diagnosis of dementia, were cognitively impaired, and dependent on staff for assistance with activities of daily living. Staff woke and dressed the residents early in the morning without consideration of the resident's preferences for waking and for staff convenience. The facility census was 81. Review of the facility policy Dignity, revised 9/30/22, showed the following: -Each resident has the right to be treated with dignity and respect. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe and homelike environment when it failed to maintain resident rooms and other areas within the facility in good working order. This deficient practice had the potential to affect residents, staff, and visitors of the facility. The census was 92. 1. Observations on 4/10/23 showed the following: -At 10:55 A.M. in occupied room [ROOM NUMBER]-2 gouges to the drywall at the head of the resident's bed. -At 3:30 P.M. in room [ROOM NUMBER]-1 the closet door was held in place in the track with one set of rollers on one side of the door, the other rollers were off the track and the door hung half off the track. Resident #54 resided in the room and said he/she did not know how long it had been off track; -At 11:27 A.M. [...]

Inspectors wroteBased on observation, interview and record review, facility staff failed to ensure two residents (Resident #44 and #49), in a review of 26 sampled residents, remained free from misappropriation of property, when the resident's money came up missing and was presumed stolen. The facility also failed to ensure three residents (Resident #10, #82 and #400) medications were not misappropriated, when during a facility investigation of missing narcotics, it was discovered the narcotic medication counts for the residents were incorrect and medications could not be accounted for. The facility census was 92. Review of the facility policy Abuse-Protection of Residents dated 10/4/22 showed: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide evidence that allegations of abuse and neglect and misappropriation of resident property were thoroughly investigated for five residents (Residents #38, #198, #44, #62 and #49), in a review of 26 sampled residents. The facility census was 92. Review of the facility policy, Abuse-Protection of Residents dated 10/4/22 showed: -It is the policy of this facility to identify abuse, neglect, and exploitation of residents and misappropriation of resident property; -The facility must establish policies and procedures to investigate any such allegations and have evidence that all alleged violations are thoroughly investigated; -The written summary of the investigation should include but is not limited to: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure diagnoses of a mental disorders or intellectual disabilities, were included on the Level I (level of care) screening submitted to Central Office Medical Review Unit (COMRU) to ensure proper screening was completed to determine if a Level II Preadmission Screening and Resident Review (PASARR) (an in depth assessment of the resident's mental health and intellectual needs) was required for four sampled residents (Residents #38, #16, #52, and #54) out of 20 sampled residents, and for one closed record (Resident #7). The facility census was 92. Review of the facility policy, Pre-admission Screening and Resident Review of the resident's (PASARR), revised 10/6/22, showed the following: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident care plans were reviewed and revised appropriately, for three residents (Resident #35, #30 and #49) in a review of 20 sampled residents. The facility census was 92. Review of facility policy Comprehensive Care Plans and Revisions, issued on 03.02.22 and reviewed on 08/17/22, showed the following: -Policy: -The facility will ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team composed of individuals who have knowledge of the resident and his/her needs, and that each resident and resident representative, if applicable, is involved in developing the care plan and making decisions about his or her care; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure facility staff provided bathing and hygiene needs for three residents (Residents #28, #64, and #147), in a review of 20 sampled residents who were unable to perform their own activities of daily living (ADL's). The facility census was 92. Review of the facility policy Activities of Daily Living (ADLs), issued on 12/11/2018, and last reviewed on 08/22/2022, showed the following: -The resident will receive assistance as needed to complete ADLs; -Any change in the ability to perform ADLs will be documented and reported to the licensed nurse; -Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a meaningful activities program for three residents (Resident's #35, #38, and #64) who could not attend group activities in a sample of 20 residents. The facility failed to provide activities in Braille for one blind resident (Resident #35). The census was 92. Review of the facility Activities Policy, undated, showed the following: -Activity practice is based on assessment, development, implementation, documentation, and evaluation of the programs provided and the unique needs and interests of each individual served; -Each resident is treated as an individual and encouraged to be involved in-group, independent and/or individual activities. -Due to some residents' physical limitations, group activities are not possible. There may also be residents who prefer to be involved only on an in-room basis. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two sampled residents (Resident #198 and #69), with tracheostomies and a tracheostomy tube (a two to three inch long curved metal or plastic tube placed in a surgically created opening (tracheostomy) in the windpipe to keep it open and for delivery of oxygen of 20 sampled residents, staff knew where emergency respiratory supplies were located and what the supplies included. The facility also failed to identify respiratory needs and interventions on the resident's base line care plan on admission, ensure physicians orders for oxygen and tracheostomy tube care were obtained, and proper size and style tracheostomy tube was listed on one resident's (Resident #198) care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure two residents with mental disorders (Resident #16 and #30), in a review of 20 sampled residents, received individualized treatment and services to meet their needs. The facility failed to adequately develop and implement meaningful interventions, including non-pharmacological interventions, alternate strategies, or to ensure the residents received timely and appropriate treatment or services to address the residents' psychosocial well-being. The facility census was 92. Review of the facility's policy Behavioral Health Services, dated 8/29/22, showed the following: -The facility will provide behavioral health care and services that create an environment that promotes emotional and psychosocial well-being, meets each resident's needs, and includes individualized approaches to care; [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure one resident who received psychotropic medication (Resident #14), in a review of 20 sampled residents, had an appropriate diagnosis for the use of psychotropic medications and failed to attempt non pharmacological interventions prior to administration of the psychotropic medication. The facility also failed to obtain stop dates of 14 days or less for PRN (as needed) psychotropic medications (a chemical substance that changes brain function and results in alterations in perception, mood, consciousness or behavior) for one sampled resident (Resident #198). The facility census was 92. Review of the facility's policy Unnecessary Medication, dated 08/30/22, showed the following: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility provided the services of a Registered Dietitian licensed in Missouri. The facility did not have a dietary manager, the previous dietary manager left employment at the facility three days prior to entrance of the survey. The facility census was 92. Review of facility policy, Nutrition Assessment, revised 12.16.21 and reviewed: 04/27/22, showed the following: -A representative from the Food and Nutrition Services department visits all residents upon admission and routinely thereafter. Food preferences, nutritional history and a visual assessment are documented. Each resident receives a comprehensive nutrition assessment to determine nutritional needs on admission, annually and when the resident becomes at risk for compromised nutritional status; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide each resident with a palatable meal served at appetizing temperatures and texture and that conserved nutritive value and flavor. The facility census was 92. Review of the undated facility policy, Keeping Hot Food Hot and Cold Food Cold, showed the following: -Not only is it important for us to keep food safe during delivery, storage and preparation, but we must also ensure that standard practices are followed during the holding of hot and cold food items. -Bacteria can grow at a much higher rate at room temperature. Therefore, we should keep hot food hot and cold food cold. Review of the undated facility policy, Tools for Food Preparation, showed the following: -There is a recipe for each item on the menu; -The ingredients needed for the item are listed; -Any necessary equipment is listed; [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure resident care equipment was in safe working order. The facility census was 92. Review of the maintenance director's Work History Report, dated 4/19/23, showed the following: -Due Date Timeframe: Last 12 Months; -Category: Beds -Electric; -Inspect electrical enclosures for cracks or other damage. Remove bed from service, contact manufacturer's customer service; -Inspect power cord for damage including the plug and strain relief. Remove bed from service, contact manufacturer's customer service; -Verify that all bed control switches operate correctly, contact manufacturer's customer service to assist in trouble shooting, remove the bed from service until problem has been resolved; -No documentation of Preventative Maintenance Inspections and Problem Resolution tasks completed from 4/30/22 to 4/30/23. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the correct bed numbers and mattresses matching two current residents (Resident #28 and #69) who had bed rails affixed to their beds, in a sample of 20 residents. The facility also failed to complete entrapment assessments for four residents with side rails (Resident #14, #35, #28, #69) to ensure the environment remained safe and free of accident hazards. The facility census was 92. Review of the facility policy, Bed Rails - Safe and Effective Use of Bed Rails, revised 12/30/2022, showed the following: -Policy: -To prevent entrapment and other safety hazards associated with bed rail use; -Assess the resident for risk of entrapment from bed rails prior to installation; -Entrapment, this is an event in which a resident is caught, trapped, or entangled in the space in or about the bed rail; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure visitation for two residents (Resident #30 and #49), in a review of 20 sampled residents, who were family members and both resided in the facility. The census was 92. Review of the facility policy, Visitation Rights, last revised 11/28/22, showed the following: -The facility will ensure each resident right to visitation is observed. The facility shall not restrict visitation without a reasonable clinical or safety cause; -Residents family members are not subject to visiting hour limitations or other restrictions not imposed by the resident, with the exception of reasonable clinical and safety restrictions; -Visitation should be person-centered, consider the residents' physical, mental and psychosocial well-being and support their quality of life. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the appropriate state-designated authority for a Level II Preadmission Screening and Resident Review (PASARR) to ensure residents with diagnoses of a mental disorder or intellectual disability had a DA-124 level I screen (used to evaluate for the presence of psychiatric conditions to determine if a preadmission screening/resident review (PASARR ) level II screen is required) completed as required for one closed record review (Resident #7), and one resident (Resident #35), of 20 sampled residents. The facility census was 92. Review of the facility policy, Pre-admission Screening and Resident Review of the resident's (PASARR), revised 10/6/22, showed the following: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan, which was culturally-competent and trauma-informed, for one resident (Residents #30) in a sample of 20 residents, in order for the resident to attain or maintain their highest practicable physical, mental and psychosocial well-being. The facility census was 92. Review of facility policy Comprehensive Care Plans and Revisions, issued on 03/02/22 and reviewed on 08/17/22, showed the following: -Policy: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure one resident's (Resident #19), of 20 sampled residents, inhaled medication was administered correctly. Staff also failed to confirm percutaneous endoscopic gastrostomy (PEG) tube (a tube through the skin and the stomach wall) placement prior to medication administration. The facility census was 92. Review of the facility policy, Metered Dose Inhaler Use, dated 11/10/22, showed the following: -The facility will provide Metered Dose Inhaler Use in accordance with professional standards of practice; -Instruct the resident to exhale fully. Then, place the MDI into the resident's mouth and tell the resident to close the lips around it using a closed mouth technique; -Instruct the resident to press down on the prescribed MDI once as the resident starts breathing in slowly through the mouth; [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assessment, monitoring, care, treatment, protection from bacteria that cause infection, physician notification, and other interventions for a new open and bleeding wound for one resident (Resident #38), in a sample of 20 residents. The resident was on anticoagulant (blood thinner) medication, and a history of cellulitis (infection of the tissue). The resident's leg wound had been bleeding according to staff for about a month and the resident's wound had green drainage. The facility census was 92. Review of Resident #38's annual Minimum Data Set (MDS), a federally mandated assessment, dated 2/16/23, showed the following: -Diagnosis include cellulitis both lower extremities, lymphedema, and morbid obesity; -Cognitively intact; -Transfers did not occur (bed bound); [...]

Inspectors wroteBased on observation and interview, the facility failed to follow proper sanitation and food handling practices in the kitchen. The facility census was 101. 1. Review of the facility disposable glove policy, dated 2/1/12 showed gloves should be changed before beginning a new task, after handling raw food, and before handling cooked or ready to eat food. 2. Observation on 08/20/19 between 9:24 A.M. and 1:15 P.M., during the inspection of the kitchen, showed the following: -A thick layer of grease and debris on the range hood baffle filters; -A thick layer of black debris on the bottom of the convection oven; -A thick layer of gray/black debris on the bottom of both ovens; -Several bowls, plates, and trays, used during the noon meal service, had water droplets on them where they had been put away wet; [...]

Inspectors wroteBased on observation and interview, the facility failed to keep the floors, doors, and walls in good repair. The census was 101. Observations from 8/21/19 to 8/23/19, showed the following: -In room [ROOM NUMBER], multiple scraped areas along the bottom of the door; -In room [ROOM NUMBER], multiple scraped areas along the bottom of the door; -In room [ROOM NUMBER], multiple scraped areas along the bottom of the door and multiple areas of chipped paint around the door jamb to the bathroom; -In room [ROOM NUMBER], multiple scraped areas along the bottom of the door and multiple areas of chipped paint around the door frame to the bathroom; -In room [ROOM NUMBER], multiple scraped areas along the bottom of the door; -In room [ROOM NUMBER], multiple scraped areas along the bottom of the door; -In room [ROOM NUMBER], multiple scraped areas along the bottom of the door; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a background check and Employee Disqualification List (EDL; a listing of individuals who have been determined to have abused, neglected or misappropriated funds or property of a resident) check for one newly hired employee (Certified Nurse Aide (CNA) I), and failed to check the Nurse Aide Registry prior to hire for six out of ten newly hired employees (Licensed Practical Nurse (LPN) G, Housekeeping Staff H, CNA I, CNA J, Maintenance Supervisor K, Dietary Staff L and Housekeeping Staff N) to ensure they did not have a Federal Indicator (the individual with a Federal Indicator cannot work in a certified long-term care facility). The facility census was 101. 1. Review of the facility's policy, Protection of Residents: Reducing the Threat of Abuse and Neglect, dated 2/2018, showed the following: [...]

Inspectors wroteBased on interview and record review, the facility failed to provide a notice of transfer to the resident and/or resident representative when three residents (Residents #69, #75, and #76), in a review of 23 sampled residents, were transferred to the hospital. The facility census was 101. 1. Review of Resident #75's census report showed the following: -The resident was sent from the facility to the emergency room and admitted to the hospital on [DATE]; -The resident was readmitted to the facility on [DATE]. Review of the resident's medical record showed no documentation the facility notified the resident/representative of the resident's transfer to the hospital on 7/8/19. 2. Review of resident #69's census report showed the resident was transferred from the facility to the emergency room on 8/10/19. [...]

Inspectors wroteBased on interview and record review, the facility failed to vaccinate eligible residents with the pneumococcal vaccines as indicated by the facility's policy and the current Centers for Disease Control (CDC) guidelines for three residents (Residents #5, #21, and #79), in a review of 23 sampled residents. The facility census was 101. 1. Review of the facility policy Influenza Vaccine, Pneumococcal Vaccine, and Flu Outbreak Management, last revised 3/3/17, showed the following: -The facility must follow state rules and regulations regarding physician-approved policies and procedures that incorporate physician orders for the administration of the influenza and pneumococcal vaccines into physician standing orders; [...]