Aria of Brookfield

In the surveyor’s words

From the most serious findings on record at Aria of Brookfield, in the surveyor’s own words.

• Immediate jeopardy, isolatedF686Nov 5, 2024

  Based on observation, interview, and record review, the facility did not ensure 3 of 3 residents (R) reviewed (R1, R2, and R3) had a comprehensive assessment and care plan to prevent and heal pressure injuries. R1 was admitted to the facility on [DATE]. Upon admission, R1 had no open wounds or pressure injuries. R1 was assessed to be at risk for pressure injuries and to need extensive assistance with bed mobility. On 7/12/24, R1 developed a blister to the right heel. An RN assessment was not completed until 7/17/24. On 7/12/24, R1's right heel blister was inaccurately assessed as Stage 1 pressure injury with 100% granulation. The care plan does not indicate heel offloading was an intervention prior to R1 developing a blister to the right heel. […]

• Immediate jeopardy, isolatedF689Nov 5, 2024

  Based on observations, interviews, and record review, the facility did not ensure that 1 of 1 resident (R5) reviewed for elopement was provided adequate supervision and interventions to prevent elopement and ensure safety. R5 had a Wanderguard placed on admission for exit seeking behaviors. R5 was assessed as a non-smoker on admission. On 10/8/24, R5 cut his Wanderguard off. A new Elopement Risk Assessment was completed and scored a higher risk for elopement than the assessment on admission, but the facility staff determined that R5 did not require the Wanderguard. Additional supervision was not put in place by the facility. […]

• Immediate jeopardy, isolatedF686Oct 16, 2023

  Based on observation, interview and record review, the facility did not ensure that residents with a pressure injury (PI) or at risk for PIs received necessary treatment and services, consistent with professional standards of practice, to prevent the development of PIs and to promote healing for 5 of 6 residents (R) reviewed for PIs. (R3, R17, R4, R2, and R18) R3 was admitted to the facility without any PIs. R3 developed multiple stage 3 PIs, and recurrent PIs, one of which developed into a stage 4 PI. The facility had no positioning program for off-loading pressure and inconsistent assessments of the multiple PIs. This resulted in 3 hospitalization s over the last 2 months due to deteriorating wound condition. R17 was admitted to the facility without any PIs. […]

• Immediate jeopardy, isolatedF686Apr 3, 2023

  Based on interview and closed record review, the facility did not ensure that residents with a pressure injury or at risk for pressure injuries received necessary treatment and services, consistent with professional standards of practice, to prevent the development of pressure injuries and to promote healing for 1 (R19) of 5 Residents reviewed for pressure injuries. R19 was readmitted to the facility on [DATE] without any pressure injuries. On 11/1/22, R19 developed a Stage 3 sacrum pressure injury. There was no revision to R19's skin integrity care plan after this development. On 11/8/22, R19's sacrum pressure injury was noted to have 100% slough and the treatment was changed to Santyl & border foam dressing daily. […]

• Immediate jeopardy, isolatedF698Dec 6, 2022

  Based on interview and record review, the Facility did not ensure 3 of 3 Residents (R3, R6, & R7) reviewed for dialysis received such services consistent with professional standards of practice and the comprehensive person-centered care plan. There are 16 Residents in the Facility who receive dialysis, 15 who are receiving dialysis in a clinic located on property and 1 Resident who goes out for dialysis. R3 was admitted to the facility on [DATE] with diagnoses which include end stage renal disease & dependence on hemodialysis. The dialysis center was unaware R3 had been admitted to the facility and R3 was not placed on the list of residents needing dialysis. R3 did not receive dialysis on Tuesday 11/15/22 & Thursday 11/17/22. […]