Inspection Reports for Kenosha Brookside Care Center

The inspection was conducted due to a complaint investigation regarding a significant medication error where Resident 1 (R1) was administered Resident 8's (R8) medications, resulting in harm to R1.

The facility failed to ensure residents were free from significant medication errors when R1 was given R8's medications, causing R1 to become lethargic and require hospitalization. The Licensed Practical Nurse (LPN) involved was suspended and resigned. The facility's medication administration policy requires verification of resident identity, which was not followed.

The visit was complaint-related due to a medication error where R1 was administered R8's medications. The error was substantiated as actual harm, with R1 hospitalized. The LPN responsible was suspended and resigned.

Surveyors entered the facility on 03/10/2025 to complete a complaint and verification survey regarding allegations of narcotic/medication diversions and other mistreatment incidents reported in February 2025.

The facility failed to timely report a missing narcotic medication incident to the State Agency and Law Enforcement, delayed reporting misappropriation allegations, and did not thoroughly investigate or report two allegations of mistreatment involving residents. Additionally, one resident did not receive appropriate assessment and care for foot pain resulting in fractures.

Complaint investigation triggered by allegations of narcotic/medication diversions and mistreatment incidents involving residents in February 2025. The facility failed to report one of three reportable incidents timely and did not thoroughly investigate two allegations of mistreatment involving residents R9 and R12.

The inspection was conducted to investigate a complaint regarding the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing in residents, specifically focusing on Resident 1 who developed a facility-acquired deep tissue injury pressure ulcer.

The facility failed to ensure that Resident 1's pressure ulcer was properly monitored and treated according to physician orders and the resident's care plan. Documentation showed lack of frequent repositioning, skin checks, heel elevation, and use of prescribed pressure-relieving devices. Interviews with staff revealed no recall of care provided, and no documentation was found to support proper care delivery.

The investigation was complaint-related, focusing on Resident 1's pressure ulcer development. The complaint was substantiated as the facility failed to provide adequate care and documentation to prevent and treat the pressure ulcer.

The inspection was conducted to investigate complaints regarding the facility's failure to ensure discharge summaries were completed for discharged residents and to assess compliance with performance review requirements for Certified Nurse Aides.

The facility failed to ensure discharge summaries were completed for two sampled discharged residents, compromising continuity of care. Additionally, the facility failed to complete timely annual performance reviews for three of five Certified Nurse Aides as required by policy.

The complaint investigation revealed that two residents (R393 and R140) were discharged without completed discharge summaries. Interviews with the Director of Nursing, Registered Nurse, Social Services Director, and Rehab Care Coordinator confirmed the absence of discharge summaries and discharge notes. Additionally, the facility did not complete annual performance reviews timely for three Certified Nurse Aides, as confirmed by personnel file reviews and interviews with the Director of Nursing, Assistant DON, and Administrator.

The inspection was conducted to evaluate compliance with regulatory requirements related to discharge procedures, dialysis care, and staff performance reviews at Brookside Care Center.

The facility failed to ensure discharge summaries were completed for two discharged residents, failed to ensure proper medication administration and communication with the dialysis center for one resident, and failed to complete timely annual performance reviews for three of five Certified Nurse Aides.

This document is a Statement of Deficiencies and Plan of Correction for Brookside Care Center, summarizing the findings from the survey completed on 08/09/2023.

No health deficiencies were found during the survey.

The inspection was conducted due to concerns about the facility's failure to provide appropriate pressure ulcer care and prevent new ulcers from developing, specifically related to one resident (R10) who developed a facility-acquired Stage 2 pressure injury.

The facility did not consistently assess R10's pressure injury nor revise the care plan accordingly. Documentation inconsistencies and lack of care plan updates were noted despite ongoing wound treatment. The wound was identified as a Stage 2 pressure injury with varying tissue type assessments by staff, some of whom were not wound certified.

The visit was complaint-related, focusing on the care and treatment of a pressure injury for resident R10. The complaint was substantiated with findings of inconsistent assessment, lack of care plan revision, and documentation issues.