Inspection Reports for
Life Care Center of Brookfield
315 HUNT ST, BROOKFIELD, MO, 64628-2412
Back to Facility ProfileDeficiencies (last 8 years)
Deficiencies (over 8 years)
15.5 deficiencies/year
Deficiencies are regulatory findings recorded during state inspections.
182% worse than Missouri average
Missouri average: 5.5 deficiencies/yearDeficiencies per year
80
60
40
20
0
Occupancy
Latest occupancy rate
65% occupied
Based on a February 2025 inspection.
This facility has shown a decline in demand based on occupancy rates.
Occupancy rate over time
Inspection Report
Complaint Investigation
Census: 78
Deficiencies: 1
Date: Feb 20, 2025
Visit Reason
The inspection was conducted due to a complaint investigation regarding a significant medication error involving Resident #1, where the resident was administered another resident's medications, resulting in adverse health effects.
Complaint Details
The complaint investigation substantiated a medication error where Resident #1 received another resident's medications followed by his own, causing a drop in blood pressure and requiring IV fluids. The error was confirmed by staff interviews and medical record reviews.
Findings
The facility failed to ensure Resident #1 was free from significant medication errors. Resident #1 was given another resident's medications followed by his own, causing low blood pressure, lethargy, and weakness requiring intravenous fluids. The investigation revealed staff errors in medication administration procedures and inadequate communication with the physician.
Deficiencies (1)
F 0760: The facility failed to ensure residents were free from significant medication errors. Resident #1 was administered Resident #3's medications and then his own, resulting in adverse health effects including low blood pressure and lethargy.
Report Facts
Facility census: 78
IV fluid administration: 1500
Blood pressure readings: Multiple blood pressure readings documented for Resident #1 showing hypotension after medication error
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN B | Licensed Practical Nurse | Involved in medication administration and communication with physician after medication error |
| CMT A | Certified Medication Technician | Administered wrong medications to Resident #1 and reported the error |
| RN E | Registered Nurse | Aware of medication error and commented on staff responsibilities |
| DON | Director of Nursing | Notified of medication error and involved in follow-up and staff education |
| NP | Nurse Practitioner | Provided medical orders and commented on the medication error's impact |
| RN/Staff Development Coordinator D | Staff Development Coordinator | Provided nursing staff education on medication administration after the error |
| Physician | Informed about medication error and provided orders for Resident #1 | |
| Administrator | Commented on the significance of the medication error and staff expectations |
Inspection Report
Plan of Correction
Census: 78
Deficiencies: 2
Date: Feb 20, 2025
Visit Reason
The document is a Statement of Deficiencies and Plan of Correction for Life Care Center of Brookfield following a survey conducted on 02/20/2025. It addresses medication administration errors and compliance with regulatory requirements.
Findings
The facility failed to ensure residents were free of significant medication errors, evidenced by a medication error involving Resident #1 receiving another resident's scheduled medications, resulting in adverse health effects. The facility's policies and procedures on medication administration and resident medication rights were reviewed and found deficient.
Deficiencies (2)
F 760: The facility failed to ensure residents were free of significant medication errors, including administering the wrong medications to Resident #1, causing low blood pressure and other adverse effects. Medication administration policies and procedures were not properly followed.
A4060: All medication errors and adverse reactions must be reported immediately to the nursing supervisor and resident's physician. This regulation was not met as evidenced by a Class II medication error related to F 760.
Report Facts
Facility census: 78
Inspection Report
Routine
Census: 89
Deficiencies: 2
Date: Dec 5, 2024
Visit Reason
The inspection was conducted to assess compliance with food safety, infection prevention and control, and proper care practices in the facility.
Findings
The facility failed to maintain ice machines in a sanitary condition, store food properly, and ensure proper infection control practices including Enhanced Barrier Precautions, hand hygiene, and cleaning of medical equipment and wound care supplies. Several residents were affected by these deficiencies.
Deficiencies (2)
F0812: The facility failed to ensure ice machines were free of black debris, had appropriate air gaps, clean water filters, and food was stored off the floor and properly sealed. A ceiling vent had debris buildup.
F0880: The facility failed to provide infection prevention and control for residents, including failure to use Enhanced Barrier Precautions, improper hand hygiene during incontinence care, inadequate cleaning of glucometers between residents, and improper cleaning of wound care equipment.
Report Facts
Facility census: 89
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in glucometer cleaning deficiency observations and interviews |
| LPN B | Licensed Practical Nurse | Named in failure to use Enhanced Barrier Precautions during tracheostomy and feeding tube care |
| CNA C | Certified Nursing Assistant | Named in failure to perform proper hand hygiene and glove changes during incontinence care |
| CNA D | Certified Nursing Assistant | Named in failure to perform proper hand hygiene and glove changes during incontinence care |
| Dietary Manager | Dietary Manager | Interviewed regarding ice machine cleaning and food storage practices |
| Maintenance Director | Maintenance Director | Interviewed regarding ice machine maintenance and ceiling vent cleaning |
| Infection Preventionist | Infection Preventionist/Wound Care Nurse | Observed and interviewed regarding wound care and infection control practices |
| Director of Nursing | Director of Nursing | Interviewed regarding infection control policies and staff expectations |
| Administrator | Administrator | Interviewed regarding staff expectations for infection control and PPE use |
Inspection Report
Plan of Correction
Census: 89
Deficiencies: 6
Date: Dec 5, 2024
Visit Reason
The inspection was conducted as a standard survey to assess compliance with federal and state regulations regarding food safety, infection prevention and control, and other health and safety requirements at Life Care Center of Brookfield.
Findings
The facility was found deficient in food procurement and safety practices, including issues with ice machines, food storage, and cleanliness. Infection prevention and control deficiencies were identified related to hand hygiene, cleaning of medical equipment, and use of enhanced barrier precautions for residents with specific care needs.
Deficiencies (6)
F812 Food safety requirements were not met as the facility failed to ensure ice machines were clean, food items were stored properly off the floor, and food containers were sealed and labeled correctly. The facility census was 89.
F880 The facility failed to provide adequate infection prevention and control for four residents, including improper use of enhanced barrier precautions, inadequate cleaning of glucometers, and failure to follow hand hygiene protocols.
A4086 Residents were not cared for using acceptable infection control procedures to prevent the spread of infection, violating Missouri state regulations.
A7015 Food was not protected from contamination during storage, preparation, and service, violating Missouri state regulations.
A7017 Food items were stored above the floor in a manner that did not protect them from contamination, violating Missouri state regulations.
A7042 Ice storage and dispensing did not prevent contamination, including lack of proper air gap and storage of ice utensils, violating Missouri state regulations.
Report Facts
Facility census: 89
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Dietary Manager | Interviewed regarding food safety and ice machine cleaning procedures | |
| Maintenance Director | Interviewed regarding ice machine maintenance and cleaning | |
| LPN A | Licensed Practical Nurse | Observed and interviewed regarding glucometer cleaning and blood sugar testing |
| LPN B | Licensed Practical Nurse | Observed and interviewed regarding tracheostomy care and infection control practices |
| Director of Nursing | DON | Interviewed regarding staff training on infection control and glucometer cleaning |
| Infection Preventionist | Interviewed regarding infection control policies and staff education | |
| IP/Wound Care Nurse | Observed wound care procedures and dressing changes | |
| CNA C | Certified Nursing Assistant | Observed providing incontinence care and hand hygiene |
| CNA D | Certified Nursing Assistant | Observed providing incontinence care and hand hygiene |
| Administrator | Interviewed regarding staff PPE use and infection control expectations |
Inspection Report
Life Safety
Census: 89
Capacity: 120
Deficiencies: 8
Date: Dec 5, 2024
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code and related fire safety regulations at Life Care Center of Brookfield.
Findings
The facility was found deficient in multiple areas related to fire safety, including accumulation of lint in dryers, unsealed vertical openings, sprinkler system maintenance, corridor door integrity, HVAC ventilation cleanliness, and electrical equipment safety. These deficiencies had the potential to affect various numbers of residents and staff in multiple smoke compartments.
Deficiencies (8)
K100: The facility failed to ensure the laundry dryers were free of excess lint buildup, presenting a fire hazard affecting 22 residents and others.
K311: The facility failed to maintain fire-resistant barriers in vertical openings and ceiling gaps, affecting six residents and others in two smoke compartments.
K353: The facility failed to maintain sprinkler heads free of debris and corrosion, affecting 27 residents and others in four smoke compartments.
K363: The facility failed to maintain corridor doors to resist smoke passage, affecting 40 residents and others in two smoke compartments.
K521: The facility failed to ensure independently-motorized ventilation units were free of debris buildup, affecting 11 residents and others in three smoke compartments.
K919: The facility failed to ensure electrical equipment was installed and maintained per NFPA 70, affecting six residents and others in three smoke compartments.
K920: The facility failed to ensure power strips and extension cords were used properly and safely, affecting 33 residents and others in four smoke compartments.
K921: The facility failed to provide complete documentation for electrical receptacle testing and maintenance, affecting all 89 residents and others in eight smoke compartments.
Report Facts
Facility capacity: 120
Census: 89
Residents potentially affected by lint buildup: 22
Residents potentially affected by sprinkler issues: 27
Residents potentially affected by corridor door deficiencies: 40
Residents potentially affected by ventilation debris: 11
Residents potentially affected by electrical power strip issues: 33
Residents affected by electrical receptacle documentation deficiency: 89
Inspection Report
Complaint Investigation
Census: 90
Deficiencies: 2
Date: Dec 4, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding failure to provide appropriate treatment and care according to physician orders, including medication administration and skin assessments.
Complaint Details
The complaint investigation found that Resident #6 did not receive ordered medications and breathing treatments due to pharmacy delays and lack of staff notification to the physician, contributing to respiratory failure and hospitalization. Resident #4 developed a pressure ulcer from cast rubbing that was not detected due to inadequate skin assessments.
Findings
The facility failed to ensure Resident #6 received medications and treatments as ordered upon admission, resulting in severe respiratory issues and hospitalization. The facility also failed to adequately assess Resident #4's skin condition after a fractured humerus and application of a partial cast, leading to an open, draining wound in the axilla.
Deficiencies (2)
F 0684: The facility failed to provide appropriate treatment and care according to physician orders for Resident #6, including timely administration of medications and breathing treatments, resulting in actual harm.
F 0684: The facility failed to adequately assess and monitor Resident #4's skin condition under a partial cast, resulting in an open, draining wound caused by cast rubbing.
Report Facts
Facility census: 90
Resident #4 wound size: 5
Resident #4 wound size width: 3
Resident #4 wound size depth: 1
Resident #4 Braden score: 17
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN D | Licensed Practical Nurse | Reported on medication order faxing and pharmacy delays for Resident #6 |
| LPN A | Licensed Practical Nurse | Charge nurse on 11/25/23 who reported resident lethargy and medication delays for Resident #6 |
| LPN E | Licensed Practical Nurse | Charge nurse on 11/24/23 who administered some medications from emergency kit and reported lack of pharmacy delivery for Resident #6 |
| Nurse Practitioner | Followed Resident #6's care and noted missed medications and breathing treatments | |
| Administrator | Acknowledged lack of medication administration and pharmacy delivery on admission for Resident #6 and inadequate skin assessments for Resident #4 | |
| LPN C | Licensed Practical Nurse | Reported on Resident #4's cast causing skin wound and lack of weekly skin assessments |
| Director of Nursing | Reported on Resident #4's wound caused by cast rubbing and need for thorough skin assessments | |
| CNA B | Certified Nurse Aide | Described Resident #4's cast and wound |
Inspection Report
Routine
Census: 81
Deficiencies: 1
Date: Jul 13, 2023
Visit Reason
The inspection was conducted to assess the facility's compliance with resident rights and care standards, specifically focusing on respecting resident self-determination and preferences for waking and daily routines.
Findings
The facility failed to respect the rights of residents with dementia by waking and dressing them early in the morning without consideration of their preferences. Multiple residents were observed being awakened and taken to breakfast well before their preferred times, causing distress and dissatisfaction among residents and family members.
Deficiencies (1)
F 0561: The facility failed to honor residents' rights to self-determination by waking and dressing residents early without regard to their preferences, particularly for residents with dementia requiring assistance with activities of daily living.
Report Facts
Facility census: 81
Number of residents reviewed: 20
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA O | Certified Nurse Aide | Named in relation to waking residents early starting at 3:30 A.M. and causing distress |
| NA P | Nurse Aide | Reported early wake-up practices and expressed upset about forced resident awakening |
| LPN B | Licensed Practical Nurse | Provided statements about appropriate wake-up times and resident preferences |
| RN S | Registered Nurse, Unit Charge Nurse | Stated that residents should be allowed to sleep if they want to |
| Interim DON | Director of Nursing | Discussed facility policies on resident wake-up times and lack of a get-up list |
| Administrator | Facility Administrator | Stated staff should follow resident and family preferences regarding wake-up times |
Inspection Report
Complaint Investigation
Census: 94
Deficiencies: 2
Date: May 11, 2023
Visit Reason
The inspection was conducted in response to allegations of verbal abuse involving a resident (Resident #32) at Life Care Center of Brookfield.
Complaint Details
The complaint involved an allegation of verbal abuse by Licensed Practical Nurse PP toward Resident #32 on 5/9/23. The allegation was substantiated by interviews and record review but was not reported to the state survey agency as required.
Findings
The facility failed to report an allegation of verbal abuse by a Licensed Practical Nurse against a resident. Interviews and record reviews showed the allegation was not reported to the state survey agency as required.
Deficiencies (2)
F609 Reporting of Alleged Violations: The facility failed to report an allegation of verbal abuse for Resident #32 to the state survey agency within required timeframes.
A8023 Develop/Implement A/N Policies: The facility did not develop and implement policies prohibiting mistreatment, neglect, and abuse, and failed to require reporting of such incidents as evidenced by the F609 deficiency.
Report Facts
Facility census: 94
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse PP | Named in verbal abuse allegation against Resident #32 | |
| Certified Nurse Assistant H | Interviewed regarding the abuse incident involving Resident #32 | |
| Director of Nurses | Director of Nurses (DON) | Interviewed about awareness of staff yelling at residents |
| Administrator | Administrator | Interviewed about reports of staff yelling and handling of abuse allegation |
Inspection Report
Complaint Investigation
Census: 96
Deficiencies: 4
Date: Apr 27, 2023
Visit Reason
The inspection was conducted due to a complaint investigation regarding medication misappropriation and significant medication errors at Life Care Center of Brookfield.
Complaint Details
The complaint investigation substantiated that Resident #18 experienced misappropriation of medication when oxycodone tablets were switched with loratadine tablets, and Resident #1 experienced a significant medication error with levothyroxine administration without diagnosis. Immediate Jeopardy was identified but later lowered to a D level after corrective actions.
Findings
The facility failed to ensure one resident was free from misappropriation of medication when oxycodone tablets were exchanged with loratadine tablets, resulting in untreated pain. Additionally, the facility failed to ensure another resident was free from a significant medication error involving administration of levothyroxine without a diagnosis, putting the resident at risk.
Deficiencies (4)
F602: The facility failed to ensure one resident was free from misappropriation of medication when 46 oxycodone tablets were exchanged for loratadine tablets, resulting in untreated pain.
F760: The facility failed to ensure one resident was free from a significant medication error by administering levothyroxine for 50 days without a diagnosis, putting the resident at risk of complications.
A4055: The facility did not maintain a safe and effective medication system, related to the F760 deficiency.
A8023: The facility failed to develop and implement policies prohibiting mistreatment, neglect, and misappropriation of resident property, related to the F602 deficiency.
Report Facts
Facility census: 96
Medication tablets involved: 46
Medication tablets involved: 35
Medication administration duration: 50
Levothyroxine dosage: 125
Inspection Report
Annual Inspection
Census: 92
Deficiencies: 12
Date: Apr 20, 2023
Visit Reason
Annual inspection of Life Care Center of Brookfield to assess compliance with healthcare facility regulations including resident care, safety, infection control, dietary services, and equipment maintenance.
Findings
The facility was found deficient in multiple areas including failure to provide appropriate equipment for a bariatric resident, inadequate supervision and safety for residents who smoke, improper hygiene and bathing assistance, unsafe wheelchair conditions, lack of licensed dietitian on site, poor food preparation and sanitation practices, inadequate infection control procedures, and failure to maintain resident care equipment in safe working order.
Deficiencies (12)
The facility failed to provide a wheelchair and lift sling to accommodate a bariatric resident, restricting the resident to his/her room for over two years and creating safety concerns during emergency evacuation.
The facility failed to ensure safe smoking practices and supervision for residents who smoke, including failure to provide smoking aprons and monitor residents properly.
The facility failed to provide adequate bathing and hygiene assistance to residents unable to perform activities of daily living, resulting in poor personal hygiene and incomplete incontinence care.
The facility failed to ensure wheelchairs had foot rests and that residents' feet were properly supported during transport, increasing risk of injury.
The facility failed to employ a Registered Dietitian licensed in Missouri and did not have a dietary manager, impacting nutritional assessments and care planning.
The facility failed to ensure residents on pureed diets received appropriate portion sizes and failed to use spreadsheet menus to guide food preparation and serving.
The facility failed to provide palatable meals served at appropriate temperatures and textures, and food preparation lacked consistency and flavor.
The facility failed to maintain sanitary conditions in the kitchen including improper food storage, unclean equipment, lack of hair restraints, inadequate hand hygiene, and poor cleaning practices.
The facility failed to develop and implement a comprehensive water management program to prevent Legionella growth, lacked a water management team, and did not monitor residents for Legionnaires' disease.
The facility failed to ensure proper hand hygiene and glove changes during wound care and blood sugar testing, and failed to keep respiratory equipment covered to prevent contamination.
The facility failed to ensure urinary catheter tubing and bags were secured and not dragging on the floor.
The facility failed to maintain resident care equipment including wheelchairs with broken or loose brake handles, damaged arm rests, exposed wiring on beds, and broken parts on mechanical lifts.
Report Facts
Facility census: 92
Resident weight: 412
Dish machine wash temperature: 115
Dish machine rinse temperature: 116
Hoyer lift sling weight limit: 550
Hoyer lift weight limit: 660
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN R | Licensed Practical Nurse | Named in wound care and hand hygiene deficiencies |
| RN GG | Registered Nurse | Named in blood sugar testing and wheelchair transport deficiencies |
| CNA Z | Certified Nurse Assistant | Named in wound care and hand hygiene deficiencies |
| Dietary K | Dietary Aide | Named in food preparation and sanitation deficiencies |
| Dietary M | Dietary Aide | Named in food preparation and sanitation deficiencies |
| Maintenance Supervisor | Maintenance Supervisor | Named in water management and equipment maintenance deficiencies |
| Consultant Registered Dietitian | Dietitian | Named in dietary service deficiencies |
| Regional Dietitian | Dietitian | Named in dietary service deficiencies |
| Certified Nurse Assistant II | Certified Nurse Assistant | Named in equipment maintenance deficiency |
Inspection Report
Immediate Jeopardy
Census: 92
Deficiencies: 25
Date: Apr 10, 2023
Visit Reason
The survey was conducted to investigate multiple compliance and quality of care concerns including resident dignity, safety, nutrition, infection control, behavioral health, and emergency preparedness.
Findings
The facility was cited for multiple deficiencies including failure to treat residents with dignity, inadequate equipment and emergency evacuation plans for bariatric residents, unsafe smoking supervision, improper medication administration, inadequate nutrition monitoring and interventions, poor infection control practices, unsafe food handling and preparation, and failure to provide adequate behavioral health services. Immediate jeopardy was identified related to resident safety and evacuation preparedness but was removed after corrective actions.
Deficiencies (25)
F 0557: Facility failed to treat six residents with dignity and respect, including ignoring call lights and using rude language.
F 0558: Facility failed to provide appropriate wheelchair and lift sling for a resident, restricting mobility and causing pain.
F 0561: Facility failed to respect resident self-determination and choice, waking residents early against preferences.
F 0564: Facility restricted visitation for two residents without proper justification, limiting family access.
F 0584: Facility failed to maintain resident rooms and common areas in good repair, including broken closet doors and unsanitary conditions.
F 0600: Facility failed to protect one resident from mental and emotional abuse by staff and failed to investigate allegations of abuse.
F 0602: Facility failed to protect residents from misappropriation of money and medications, with missing resident funds and narcotics.
F 0610: Facility failed to thoroughly investigate allegations of abuse, neglect, and misappropriation for multiple residents.
F 0645: Facility failed to complete required PASARR Level II mental health screenings for several residents and did not incorporate recommendations into care plans.
F 0656: Facility failed to develop and implement comprehensive person-centered care plans for residents with cognitive and behavioral health needs.
F 0677: Facility failed to develop and revise care plans timely, missing updates for falls, behaviors, and code status.
F 0684: Facility failed to provide adequate respiratory care, including missing physician orders, improper oxygen delivery, and lack of emergency tracheostomy supplies.
F 0689: Facility failed to provide sufficient staff for safe evacuation of bariatric and other residents, and failed to maintain safe smoking practices.
F 0692: Facility failed to provide adequate nutritional care including lack of weight monitoring, delayed dietitian assessments, and failure to provide ordered tube feedings.
F 0695: Facility failed to employ a qualified dietitian licensed in Missouri and failed to ensure nutritional assessments were completed timely.
F 0679: Facility failed to ensure residents received appropriate portion sizes and palatable meals served at proper temperatures.
F 0812: Facility failed to maintain sanitary kitchen conditions including unclean equipment, improper food storage, and poor hand hygiene by staff.
F 0880: Facility failed to implement a water management program consistent with CDC and ASHRAE standards and failed to monitor residents for Legionnaire's disease.
F 0908: Facility failed to maintain resident care equipment in safe working order including broken wheelchair brakes, exposed bed wiring, and damaged Hoyer lift.
F 0909: Facility failed to ensure bed rails and mattresses were compatible and safe, and failed to complete entrapment assessments for residents with bed rails.
F 0740: Facility failed to provide necessary behavioral health care and services to a resident with bipolar disorder and depression, including failure to identify trauma history, provide counseling, and implement appropriate interventions.
F 0679: Facility failed to provide individualized behavioral health care and services to residents with mental disorders, including failure to implement non-pharmacological interventions and monitor medication appropriateness.
F 0758: Facility failed to ensure psychotropic medications were used appropriately, including lack of diagnosis, failure to attempt non-pharmacological interventions, and missing stop dates for PRN medications.
F 0801: Facility failed to employ a licensed dietitian in Missouri and failed to ensure timely nutritional assessments and follow-up for residents with weight loss.
F 0880: Facility failed to ensure infection prevention and control program was implemented consistent with CDC and ASHRAE standards, including lack of water management team, poor hand hygiene, and contaminated respiratory equipment.
Report Facts
Resident census: 92
Resident weight loss: 9.5
Resident weight loss: 37
Staff on night shift: 6
Residents requiring mechanical lift: 23
Residents requiring two staff assist: 15
Residents requiring stand-by assist: 22
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN R | Licensed Practical Nurse | Named in multiple findings including rude behavior, wound care, oxygen administration, and resident care |
| RN BB | Registered Nurse | Named in findings related to rude behavior and medication misappropriation |
| CNA CC | Certified Nurse Assistant | Named in findings related to rude behavior and resident interactions |
| CNA O | Certified Nurse Assistant | Named in findings related to rude behavior and resident interactions |
| LPN FF | Licensed Practical Nurse | Named in findings related to rude behavior and medication administration |
| CNA Z | Certified Nurse Assistant | Named in wound care and hygiene findings |
| CNA EE | Certified Nurse Assistant | Named in wound care and hygiene findings |
| Dietary K | Dietary Staff | Named in findings related to food preparation and hygiene |
| Dietary M | Dietary Staff | Named in findings related to food preparation and hygiene |
| Maintenance Supervisor | Maintenance Supervisor | Named in findings related to equipment and facility maintenance |
| LPN QQ | Licensed Practical Nurse | Named in wound care and oxygen administration findings |
| CNA NN | Certified Nurse Assistant | Named in blood sugar testing and infection control findings |
| RN GG | Registered Nurse | Named in blood sugar testing, oxygen administration, and resident transport findings |
| CNA MM | Certified Nurse Assistant | Named in wheelchair transport findings |
| CNA X | Certified Nurse Assistant | Named in catheter care and smoking supervision findings |
| LPN A | Licensed Practical Nurse | Named in feeding tube and smoking supervision findings |
| Administrator | Administrator | Named in multiple interviews regarding facility policies and deficiencies |
Inspection Report
Plan of Correction
Census: 82
Deficiencies: 1
Date: Dec 9, 2022
Visit Reason
This document is a statement of deficiencies and plan of correction following a survey completed on 12/09/2022 at Life Care Center of Brookfield. The visit was to address and correct a past noncompliance related to abuse and neglect.
Findings
The facility failed to ensure one resident was free from verbal and emotional abuse by a Licensed Practical Nurse (LPN A). The abuse included taunting and degrading behavior toward the resident, which was substantiated and led to the termination of the staff member.
Deficiencies (1)
CFR 483.12(a)(1) Freedom from Abuse, Neglect, and Exploitation was not met. The facility allowed LPN A to verbally abuse Resident #1 by taunting and emotionally degrading the resident during medication administration.
Report Facts
Facility census: 82
Employees mentioned
| Name | Title | Context |
|---|---|---|
| LPN A | Licensed Practical Nurse | Named in verbal and emotional abuse finding toward Resident #1 |
| Nurse Assistant B | Nurse Assistant | Provided witness statement regarding abuse incident |
| Director of Nursing | Director of Nursing | Interviewed resident and involved in abuse investigation |
| Administrator | Administrator | Notified of past noncompliance and abuse investigation |
Inspection Report
Routine
Deficiencies: 0
Date: Jul 14, 2022
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Census: 86
Deficiencies: 2
Date: Jun 6, 2022
Visit Reason
The visit was conducted to investigate allegations of abuse involving a resident at the Life Care Center of Brookfield and to review the facility's compliance with abuse prevention and reporting regulations.
Complaint Details
The investigation was complaint-related, substantiated abuse allegations involving Resident #1 were confirmed. The facility failed to report the abuse to the state survey agency within the required timeframe.
Findings
The facility was found to have failed to ensure one resident was free from verbal and physical abuse by staff, resulting in substantiated abuse allegations and termination of involved employees. The facility also failed to report the abuse allegations to the state survey agency within the required timeframe.
Deficiencies (2)
F600: The facility failed to ensure one resident was free from verbal and physical abuse by certified nurse aides, resulting in a skin tear and bruising. The abuse was substantiated and corrective actions were taken including staff termination.
F609: The facility failed to report physical and verbal abuse allegations involving one resident to the state survey agency within two hours as required. The abuse allegations were substantiated after investigation.
Report Facts
Facility census: 86
Date of incident: May 20, 2022
Date of investigation completion: Jun 6, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in abuse incident involving Resident #1 |
| CNA C | Certified Nurse Aide | Named in abuse incident involving Resident #1 |
| NA B | Witnessed abuse and provided statements | |
| RN D | Registered Nurse | Charge nurse on Alzheimer's unit during alleged event |
| RN E | Registered Nurse | Informed about the abuse incident |
Inspection Report
Complaint Investigation
Census: 88
Deficiencies: 2
Date: Aug 26, 2021
Visit Reason
The inspection was conducted following a complaint regarding a resident found outside unsupervised during high temperatures, resulting in injury.
Complaint Details
The complaint investigation was substantiated as the resident was found outside unsupervised during extreme heat, resulting in injury.
Findings
The facility failed to monitor a resident per policy while outside during extreme heat, resulting in the resident sustaining first and third degree burns. The facility lacked adequate supervision and policies to prevent such accidents during inclement weather.
Deficiencies (2)
F689 Free of Accident Hazards/Supervision/Devices: The facility failed to monitor one resident per policy while outside during high temperatures, resulting in the resident being found overheated with burns to the foot and toe.
A4073 Protective Oversight, Voluntary Leave: The facility did not ensure twenty-four hour protective oversight and supervision for residents on voluntary leave, failing to inquire about the resident's whereabouts during absence.
Report Facts
Resident census: 88
Resident body temperature: 100.4
Burn wound size: 6
Burn wound size: 7
Burn wound size: 2
Burn wound size: 1.5
Inspection Report
Complaint Investigation
Census: 97
Deficiencies: 8
Date: May 5, 2021
Visit Reason
The inspection was conducted due to complaints alleging failure to notify residents' responsible parties of changes in condition, verbal abuse by staff, inadequate care planning, and failure to prevent pressure ulcers.
Complaint Details
The complaint investigation was substantiated as the facility was found to have failed in multiple areas including notification of condition changes, protection from verbal abuse, care planning, and pressure ulcer management.
Findings
The facility was found to have multiple deficiencies including failure to notify responsible parties of residents' condition changes, verbal abuse by staff towards residents, inadequate care planning and revision, and failure to prevent and properly treat pressure ulcers.
Deficiencies (8)
F580: The facility failed to notify residents' responsible parties of changes in condition for two sampled residents. The facility census was 51 at the time of review.
F600: The facility failed to protect two residents from verbal abuse by staff, including use of inappropriate language. The facility census was 97.
F657: The facility failed to develop and revise comprehensive care plans for residents, including timely updates after changes in condition. The facility census was 97.
F684: The facility failed to ensure one resident received necessary treatment and care for pressure ulcers, including timely notification to the physician. The facility census was 97.
F686: The facility failed to identify and treat a Stage II pressure ulcer for one resident, including failure to notify the physician and obtain treatment orders. The facility census was 97.
F742: The facility failed to implement interventions to address aggressive and agitated behaviors for 18 sampled residents. The facility census was 97.
A4087: The facility failed to notify the responsible party of a significant change in condition for one resident. The facility census was 97.
A4082: The facility failed to develop and implement policies to prohibit mistreatment, neglect, and abuse of residents, including verbal abuse by staff. The facility census was 97.
Report Facts
Facility census: 97
Facility census: 51
Number of sampled residents: 18
Number of residents affected by verbal abuse: 2
Number of residents with deficient care plans: 3
Number of residents with pressure ulcers: 1
Number of residents with aggressive behavior issues: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA F | Certified Nurse Assistant | Named in verbal abuse findings and investigation. |
| CNA I | Certified Nurse Assistant | Named in verbal abuse findings and investigation. |
| LPN B | Licensed Practical Nurse | Interviewed regarding wound and care plan issues. |
| LPN C | Licensed Practical Nurse | Interviewed regarding resident behavior and verbal abuse. |
| Director of Nursing | Director of Nursing | Interviewed regarding reporting and care plan expectations. |
| Administrator | Facility Administrator | Interviewed regarding staff reporting and abuse prevention. |
| MDS Coordinator/RN H | Registered Nurse | Involved in care plan reviews and investigations. |
| Human Information Manager (HIM) H | Human Information Manager | Reported verbal abuse incident and participated in investigation. |
Inspection Report
Complaint Investigation
Census: 92
Deficiencies: 4
Date: Feb 25, 2021
Visit Reason
The inspection was conducted in response to allegations of physical abuse involving one resident at Life Care Center of Brookfield.
Complaint Details
The complaint investigation was substantiated as the facility failed to report and investigate an allegation of physical abuse involving Resident #1 and a Registered Nurse (RN A).
Findings
The facility failed to report an allegation of physical abuse involving a resident and did not conduct a timely and thorough investigation. The facility also failed to protect the resident and continued to employ the accused nurse during the investigation.
Deficiencies (4)
F609: The facility failed to report an allegation of physical abuse involving one resident within required timeframes and to appropriate officials. The facility census was 92.
F610: The facility failed to conduct a timely and thorough investigation of an alleged physical abuse incident involving one resident and a staff member. The facility census was 92.
A8023: The facility did not develop and implement written policies and procedures prohibiting mistreatment, neglect, and abuse of residents as required.
A8025: The facility failed to report allegations of abuse to the Department of Health and Senior Services and Department of Mental Health when needed.
Report Facts
Facility census: 92
Deficiencies cited: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Named in physical abuse allegation and investigation |
| CNA D | Certified Nurse Assistant | Reported the abuse allegation to RN A |
| LPN B | Licensed Practical Nurse | Involved in assessment and investigation of resident's injury |
| DON | Director of Nursing | Provided statements regarding abuse reporting policies and investigation |
Inspection Report
Routine
Deficiencies: 0
Date: Oct 15, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted to assess the facility's compliance with CMS and CDC recommended practices for COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Sep 22, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness survey and a COVID-19 Focused Infection Control Survey were conducted to assess compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended practices for COVID-19 infection control.
Report Facts
Regulatory compliance references: 42
Inspection Report
Abbreviated Survey
Deficiencies: 0
Date: Jun 2, 2020
Visit Reason
A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted on June 2, 2020 to assess the facility's compliance with CMS and CDC recommended practices related to COVID-19.
Findings
The facility was found to be in compliance with 42 CFR 483.73 related to emergency preparedness and with CMS and CDC recommended infection control practices to prepare for COVID-19.
Inspection Report
Plan of Correction
Census: 97
Deficiencies: 2
Date: Jan 6, 2020
Visit Reason
The inspection was conducted to investigate allegations of misappropriation and diversion of controlled substances at the Life Care Center of Brookfield.
Findings
The facility failed to protect residents from misappropriation of property when a resident's schedule II narcotic medication went missing. The investigation revealed discrepancies in narcotic counts and documentation errors related to controlled substance logs.
Deficiencies (2)
F602: The facility failed to protect residents from misappropriation of property as evidenced by missing hydrocodone/acetaminophen tablets for Resident #1 and inadequate controlled substance count procedures.
A8023: The facility did not develop and implement policies prohibiting mistreatment, neglect, abuse, and misappropriation of resident property and funds, as required by regulation.
Report Facts
Facility census: 97
Medication cards counted: 25
Medication cards missing: 1
Medication card value: 40
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN A | Registered Nurse | Conducted narcotic counts and investigation |
| LPN B | Licensed Practical Nurse | Checked narcotic cards with RN A |
| LPN D | Licensed Practical Nurse | Interviewed regarding narcotic counts and observations |
| CMT C | Certified Medication Technician | Counted narcotics and involved in medication diversion investigation |
| Director of Nursing | DON | Contacted regarding concerns about narcotic counts |
Inspection Report
Plan of Correction
Census: 101
Deficiencies: 12
Date: Aug 23, 2019
Visit Reason
The document is a Plan of Correction submitted in response to a federal inspection survey conducted at Life Care Center of Brookfield on 08/23/2019.
Findings
The facility was found deficient in maintaining a safe, clean, and comfortable environment, employing staff without proper background checks, providing timely notice before resident transfers, ensuring food safety, and administering required immunizations. The census during the inspection was 101 residents.
Deficiencies (12)
F584: The facility failed to maintain floors, doors, and walls in good repair, with multiple scraped areas, chipped paint, marred doors, peeling wallpaper, and stained floors observed throughout the building.
F606: The facility failed to complete background checks and Employee Disqualification List screenings for six out of ten newly hired employees, violating requirements to not employ individuals with adverse actions.
F623: The facility failed to provide timely written notice and reasons for transfer or discharge to residents and their representatives for three sampled residents transferred to the hospital.
F812: The facility failed to follow proper food safety and handling practices in the kitchen, including sanitation of equipment and use of gloves during meal service.
F883: The facility failed to ensure residents received influenza and pneumococcal immunizations according to CDC guidelines and failed to provide education and documentation regarding immunizations.
A4018: The facility failed to develop and implement written policies requiring disclosure of prior criminal history for persons hired for positions with resident contact.
A4085: The facility failed to use acceptable infection control procedures to prevent the spread of communicable disease, including timely reporting to the state division.
A6012: Floors in food preparation and storage areas were not maintained in good repair, with damaged surfaces noted.
A6015: Walls, ceilings, doors, windows, and skylights were not maintained in good repair, with damage noted.
A7002: Employees failed to properly wash hands and keep fingernails clean and trimmed.
A7057: Ventilation hoods and filters were not properly cleaned or maintained.
A7086: Equipment and utensils were not properly air dried or stored in a self-draining position after sanitization.
Report Facts
Facility census: 101
Number of sampled residents for transfer notice review: 23
Number of residents transferred to hospital: 3
Number of newly hired employees reviewed: 10
Number of employees missing required checks: 6
Inspection Report
Life Safety
Census: 101
Capacity: 120
Deficiencies: 4
Date: Aug 23, 2019
Visit Reason
The inspection was a life safety code survey conducted to assess compliance with fire safety regulations and related requirements at the Life Care Center of Brookfield.
Findings
The facility failed to maintain fire barriers and sprinkler systems properly, including unsealed openings in ceilings, gaps in range hood baffle filters, and sprinklers covered with dust and corrosion. Electrical equipment and power strips were also found to be improperly used, creating potential fire hazards.
Deficiencies (4)
K161: The facility failed to maintain the fire barrier between the first floor and attic with a one-hour fire resistance rating due to unsealed openings in ceilings, affecting 64 residents in four smoke compartments.
K324: The facility failed to ensure no gaps between range hood baffle filters and lacked a grease drip pan, posing a fire hazard in the kitchen area affecting residents and visitors.
K353: The facility failed to maintain the sprinkler system by allowing sprinklers to be covered with dust, debris, corrosion, and paint in multiple locations throughout the building.
K920: The facility failed to ensure electrical equipment and power strips were installed and used safely, with extension cords and power strips improperly placed, creating fire hazards affecting 71 residents.
Report Facts
Facility capacity: 120
Census: 101
Residents potentially affected: 64
Residents potentially affected: 71
Inspection Report
Routine
Census: 101
Deficiencies: 5
Date: Aug 23, 2019
Visit Reason
Routine inspection of Life Care Center of Brookfield to assess compliance with health and safety regulations, including facility maintenance, staff background checks, resident transfer notifications, food safety, and vaccination policies.
Findings
The facility had multiple deficiencies including poor maintenance of floors, doors, and walls; failure to complete required background checks for newly hired employees; failure to provide timely written transfer notifications to residents or their representatives; improper food handling and sanitation practices in the kitchen; and failure to vaccinate eligible residents with pneumococcal vaccines according to CDC guidelines.
Deficiencies (5)
F 0584: Facility failed to keep floors, doors, and walls in good repair, with multiple scraped doors, chipped paint, peeling wallpaper, and missing cove base observed in resident rooms and common areas.
F 0606: Facility failed to complete background checks and Employee Disqualification List checks for newly hired employees, including CNAs, LPNs, housekeeping, maintenance, and dietary staff, prior to hire.
F 0623: Facility failed to provide timely written notification to residents and/or their representatives before transfer or discharge to hospital for three residents.
F 0812: Facility failed to follow proper sanitation and food handling practices in the kitchen, including dirty range hood filters, ovens, wet dishes put away, improper thermometer cleaning, and improper use of gloves and utensils during meal service.
F 0883: Facility failed to vaccinate eligible residents with pneumococcal vaccines per facility policy and CDC guidelines, missing PCV13 vaccination for three residents despite orders and consents.
Report Facts
Facility census: 101
Number of sampled residents reviewed: 23
Number of residents with transfer notification deficiency: 3
Number of residents with pneumococcal vaccination deficiency: 3
Number of newly hired employees without proper background checks: 7
Inspection Report
Complaint Investigation
Census: 101
Deficiencies: 2
Date: Jul 1, 2019
Visit Reason
The inspection was conducted in response to allegations of abuse, neglect, exploitation, or mistreatment involving a resident who reported sexual abuse.
Complaint Details
The complaint involved an allegation of sexual abuse reported by Resident #1. The allegation was not reported to the state survey agency within the required timeframe. The facility's administrator did not report the allegation to law enforcement, believing it was untrue. The Activity Director did report the allegation to the administrator.
Findings
The facility failed to report an allegation of sexual abuse within the required two-hour timeframe. The investigation revealed that the allegation was reported late to the state survey agency, and law enforcement was not notified.
Deficiencies (2)
F609: The facility failed to report an allegation of sexual abuse within two hours to the state survey agency as required by regulation.
A8025: The administrator or employee failed to immediately report or cause a report to be made to the department when there was reasonable cause to believe a resident was abused or neglected.
Report Facts
Facility census: 101
Inspection Report
Complaint Investigation
Census: 98
Deficiencies: 2
Date: Jan 2, 2019
Visit Reason
The inspection was conducted due to a complaint investigation regarding alleged abuse of a resident by a Certified Nurse Aide (CNA).
Complaint Details
The complaint was substantiated. The facility substantiated the allegation of abuse against CNA A and terminated the employee. The incident occurred on 12/25/18 and was reported to the Director of Nursing and administration. Interviews with the resident, staff, and visitor confirmed the abuse.
Findings
The facility failed to ensure one resident was free from abuse when a CNA pinched the resident's face and told the resident to 'shut up.' The facility substantiated the allegation and terminated the CNA.
Deficiencies (2)
F600 Freedom from Abuse, Neglect, and Exploitation: The facility failed to prevent verbal and physical abuse of a resident by a CNA who pinched the resident's face and told the resident to 'shut up.'
A4074 Nursing Care per Resident Condition: Each resident shall receive personal attention and nursing care consistent with current acceptable nursing practice. This regulation was not met as evidenced by the abuse incident referenced in F600.
Report Facts
Facility census: 98
Date of alleged incident: Dec 25, 2018
Plan of correction completion date: Jan 28, 2019
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA A | Certified Nurse Aide | Named in abuse allegation and termination |
| LPN C | Licensed Practical Nurse | Reported abuse allegation to Director of Nursing |
| Director of Nursing | Director of Nursing | Interviewed resident and substantiated abuse allegation |
Inspection Report
Plan of Correction
Census: 93
Deficiencies: 2
Date: Oct 22, 2018
Visit Reason
The inspection was conducted to investigate deficiencies related to resident room/roommate changes and compliance with notification requirements.
Findings
The facility failed to provide two residents with written notice regarding room changes, including the reason for the change, before moving them. Documentation and notification processes were inadequate, and staff were unaware that written notification was required prior to room changes.
Deficiencies (2)
F559: The facility failed to provide two residents with written notice regarding a room change, including the reason, before moving them to another room. Documentation and notification were lacking in residents' records and staff interviews confirmed the deficiency.
A8019: The facility did not comply with 19 CSR 30-88.010(19) regarding resident room transfers, failing to consult residents ahead of time and prevent avoidable detriment to residents' physical, mental, or emotional condition.
Report Facts
Facility census: 93
Inspection Report
Plan of Correction
Census: 84
Deficiencies: 9
Date: Jul 19, 2018
Visit Reason
The inspection was conducted to assess compliance with federal regulations regarding resident rights, safe environment, professional standards, and care practices at Life Care Center of Brookfield.
Findings
The facility was found deficient in multiple areas including resident self-determination, safe and homelike environment, medication administration, professional standards, pressure ulcer prevention, infection control, and pharmacy services. Several residents were affected by these deficiencies.
Deficiencies (9)
F561 Resident self-determination was not ensured as one resident was not allowed to choose waking times and make choices about aspects of life in the facility.
F584 The facility failed to provide a clean and comfortable environment, with issues such as dust-covered vents, broken closet doors, and damaged floor tiles observed.
F658 The facility failed to meet professional standards by not administering medications timely and failing to obtain ordered laboratory tests for residents.
F677 The facility failed to ensure residents received necessary assistance with activities of daily living, including hygiene and oral care.
F686 The facility failed to provide adequate treatment and prevention of pressure ulcers, including failure to reposition residents and maintain skin integrity.
F689 The facility failed to provide adequate supervision and assistive devices to prevent accidents and injuries among residents.
F755 The facility failed to provide pharmaceutical services in accordance with regulations, including proper destruction of medications and documentation.
F804 The facility failed to provide food that was palatable and served at appropriate temperatures to residents.
F880 The facility failed to establish and maintain an infection prevention and control program to prevent the spread of communicable diseases.
Report Facts
Facility census: 84
Number of sampled residents: 18
Number of additional residents reviewed: 3
Number of residents affected by hygiene deficiency: 5
Number of residents at risk for pressure ulcers: 18
Employees mentioned
| Name | Title | Context |
|---|---|---|
| John Smith | Director of Nursing | Named in medication administration and care deficiencies |
Inspection Report
Life Safety
Census: 84
Capacity: 120
Deficiencies: 4
Date: Jul 19, 2018
Visit Reason
The inspection was conducted to assess compliance with the 2012 edition of the Life Safety Code of the National Fire Protection Association and related regulations, focusing on hazardous areas, corridor doors, smoking regulations, and gas equipment storage.
Findings
The facility failed to ensure hazardous areas were protected by self-closing doors and partitions, corridor doors resisted smoke passage, and metal self-closing containers in the smoking area functioned properly. Additionally, oxygen cylinders were not adequately secured or labeled, and smoking disposal areas were not properly maintained.
Deficiencies (4)
K321 Hazardous areas are not protected by self-closing doors and partitions, allowing smoke passage in multiple areas including the medical records room and kitchen door. This deficient practice potentially affected four residents and occupants in two smoke compartments.
K363 Corridor doors failed to resist smoke passage due to gaps between doors and frames in multiple resident rooms and other areas. This deficiency potentially affected all 84 residents in six of eight smoke compartments.
K741 Smoking regulations were not met as metal self-closing containers in the designated smoking area did not self-close and combustible trash was intermixed with cigarettes. This deficiency potentially affected any resident, visitor, or staff using the smoking area.
K923 Oxygen cylinders were not adequately secured or labeled to prevent confusion during emergencies. This deficiency potentially affected 23 residents in one smoke compartment.
Report Facts
Facility capacity: 120
Census: 84
Residents potentially affected by hazardous areas deficiency: 4
Residents potentially affected by corridor doors deficiency: 84
Residents potentially affected by oxygen cylinder deficiency: 23
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