Brookfield Healthcare Center

In the surveyor’s words

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

• Actual harm, isolatedF689Oct 13, 2023

  Based on observation, interview, and record review, the facility failed to implement interventions to prevent a fall with injury for one of three residents (Resident 19) with history of falls by failing to: 1. Ensure Resident 19 performed toilet transfers toward the left, unaffected side and did not place weight onto the right leg after toileting. 2. Provide Resident 19 with two-persons assistance for toilet transfers and toilet hygiene (toileting, includes managing undergarments, clothing, and incontinence products and performing cleansing before or after voiding or having a bowel movement). 3. […]

• No harm, potential for more than minimal, patternF760Dec 5, 2025

  Based on interview and record review, the facility failed to ensure one of five sampled residents (Resident 19) was free of significant medication errors, when:1. Resident 19's orders for Percocet (medication used to treat moderate or severe pain) and methocarbamol (a muscle relaxer used to relieve muscle, bone, and joint pain) were not clarified.2. Resident 19 was administered methocarbamol and Percocet together.These deficient practices had the potential to result in Resident 19 experiencing sedation (when given too much a medication that makes an individual sleepier or less conscious than intended) and respiratory arrest (when an individual stops breathing).Findings:During a review of Resident 19's admission Record (Face Sheet), the admission Record indicated Resident 19 was admitted to… […]

• No harm, potential for more than minimal, patternF757Oct 18, 2024

  Based on interview and record review, the facility failed to ensure one of three sampled residents (Residents 30) would not be administered any unnecessary medication in the form of duplicate drug therapy. (Cross Reference F756) The deficient practice created the risk for Resident 30 to receive excessive dosages of salmeterol (long-acting bcta2-adrcnergic agonist [[NAME]] medication, used to treat asthma - chronic inflammatory disease of the lungs) which are contained in both oral inhalers, Serevent Diskus (salmeterol) and Advair Diskus (a medication that contains both salmeterol and fluticasone propionate, an anti-inflammatory medicine, used to treat asthma and chronic obstructive pulmonary disease (COPD - lung disease that makes it difficult to breathe) which could lead to the resident… […]

• No harm, potential for more than minimal, patternF755Oct 13, 2023

  Based on observation, interview, and record review, the facility failed to administer Folic Acid (a medication used as a supplement for heart health) 1 mg tablet as ordered by the physician for one of four sampled residents during medication administration (Resident 28) and failed to administer Norco (a brand name for hydrocodone-acetaminophen, a combination medication used to treat pain) on time for one of five sampled residents (Resident 21.) As a result, Residents 21 and 28 did not receive medication in accordance with the physician's orders and standards of practice and had the potential to experience adverse effects (unwanted effects from a medication) and negative impact to their health and well-being. Findings: a. […]

• No harm, potential for more than minimal, patternF812Oct 13, 2023

  Based on observation, interview, and record review, the facility failed to ensure safe and sanitary food storage and food preparation practices in the kitchen when: a. Margarine was observed at 74 Degrees ( ) Fahrenheit (F). b. The ice machine baffle (slanted component used to keep ice from falling out of the bin when the door is opened) was observed with black and pink residues. c. The storage areas for the pots and pans were observed with dust and dirt residue. d. The mixer attachments were found with oil residue. e. Seven (7) resident's food trays were observed chipped and cracked. f. The refrigerator shelves were observed chipped with black and orange metal discoloration exposed. g.The trayline area was observed with black, reddish dirt and grease build up. h. […]