Brookfield Health Care Center

In the surveyor’s words

From the most serious findings on record at Brookfield Health Care Center, in the surveyor’s own words.

• Actual harm, isolatedF684Jul 23, 2026

  Based on interviews and record reviews, the facility failed to ensure that one resident (Resident #1), who had a diagnosis of diabetes mellitus (DM, a metabolic disease) and end-stage renal disease (ESRD, chronic irreversible kidney failure), who was receiving dialysis (a medical treatment that filters waste, extra salt, and fluid from the blood when the kidneys stop working) in a review of six sampled residents, received treatment and care per the facility's hemodialysis policy, when staff did not complete a pre-dialysis assessment that included a blood sugar finger stick (BSFS), did not offer the resident food prior to leaving the facility when the resident said he/she was hungry, and did not communicate with staff of the dialysis center when the resident was left in the lobby of the… […]

• Actual harm, isolatedF684Mar 18, 2026

  Based on interview and record review, the facility failed to notify the physician, timely, for one resident (Resident #3), in a review of four sampled residents, when the resident's continuous positive airway pressure (CPAP, a machine that keeps the airway open during sleep for persons with sleep apnea) mask broke on 1/24/26. The resident went 12 days in the facility without using the CPAP at night, due to not having a functioning mask available. The facility also failed to notify the physician when the resident experienced a change in condition on 01/31/26, which included low oxygen saturation, lethargy and anxiety. Staff sent the resident to the hospital on [DATE]. […]

• Actual harm, isolatedF684Oct 15, 2025

  Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of nine sampled residents, received care and treatment in accordance with professional standards of practice when the resident presented with stroke like symptoms including facial drooping on the left side, slurred speech, delayed responses, and left sided weakness on 8/25/25. The Director of Nursing (DON) advised the resident's family that given the resident's age, treatment would potentially be limited. The facility failed to send the resident to the hospital for evaluation. The resident sustained a stroke and the resident's functional abilities declined as a result. […]

• Actual harm, isolatedF689Jun 12, 2025

  Based on observation, interview and record review, the facility failed to use a gait belt (a canvas belt placed around the resident's waist to assist with ambulation and transfers), appropriately when transferring one resident (Resident #8) in a review of 16 sampled residents. Additionally, staff failed to reposition one resident (Resident #8), appropriately when staff lifted the resident by pulling on his/her pants. Staff failed to use a gait belt to transfer two residents (Resident #8 and #17) and instead, pulled on the resident's arms, back of neck and shoulders when assisting the resident from sitting to standing. The facility failed to store a portable oxygen tank securely when not in use for one resident (Resident #25). The facility census was 25. […]

• No harm, potential for more than minimal, widespreadF727Jun 12, 2025

  Based on interview and record review, the facility failed to provided a Registered Nurse (RN) eight consecutive hours a day, seven days a week. Additionally the facility failed to have a full time Director of Nursing (DON) from 05/10/25 through 06/09/25. The facility census was 25. Review of the facility's policy, Sufficient Staff Policy, revised 05/18/24, showed the following: -It is the policy of this facility to provide sufficient staff with appropriate competencies and skill sets to assure resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each resident; -Except when waived, the facility must use the services of an RN for at least eight consecutive hours a day, seven days a week; -The DON may serve as a charge nurse only… […]