Life Care Center of Brookfield

In the surveyor’s words

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

• Immediate jeopardy, isolatedF760Apr 27, 2023

  Based on interview and record review, the facility failed to ensure one resident (Resident #1) was free from a significant medication error, when staff failed to transcribe and administer levothyroxine (thyroid medication) to the correct resident. The facility administered 125 micrograms (mcg) to Resident #1 for at least 50 days when the resident did not have a diagnosis of a thyroid disorder. Because of the significant medication error, it put the resident at risk for likelihood of complications and side effects that could be caused by taking the medication. The facility census was 96. The administrator was notified of the Immediate Jeopardy (IJ) on 4/26/23 which began on 2/11/23. […]

• Immediate jeopardy, isolatedF689Apr 20, 2023

  Based on observation, interview, and record review, the facility failed to thoroughly assess one bed-bound bariatric resident (Resident #38), in a review of 20 sampled residents, to ensure the facility maintained the proper equipment to safely transfer the resident from his/her bed, and failed to ensure their policy and the resident's plan of care related to emergency evacuation procedures for a bariatric resident would be successful as they had not identified the number of staff required or the equipment necessary to safely evacuate the resident from the facility. The facility did not know the resident's current weight and could not determine if the transfer equipment available could meet the resident's weight requirement in order to safely transfer the resident without injury. […]

• Immediate jeopardy, isolatedF725Apr 20, 2023

  Based on observation, interview, and record review, the facility failed to provide sufficient staff to meet residents' needs in the event of an emergency when the facility was unsure how many staff it would require to safely evacuate one morbidly obese resident (Resident #38) of 60 sampled residents. The facility identified 23 residents that required mechanical lift transfers, 15 that required the assist of two staff and 22 that required staff stand-by assist to evacuate. Facility staff failed to ensure their policy for getting bariatric residents to safety in the event of an emergency would be successful as they had not practiced the plan. Some staff identified six staff would be enough to get Resident #1 to safety. Review of the staffing for 11:00 P.M. to 4:30 A.M. […]

• Immediate jeopardy, isolatedF740Apr 20, 2023

  Based on observation, interview, and record review, the facility failed to ensure one resident (Resident #38) in a sample of 20 residents, who presented with diagnoses of bipolar and depression and who has a history of past traumatic events, including abuse and suicide attempts, received the necessary behavioral health care services to maintain the highest practicable physical, mental and psychosocial well-being. The facility failed to obtain the resident's level II screening completed in 2016. The facility also failed to obtain a level II screening when the resident had a change in behavior and status. Staff have not been educated regarding behaviors or mental illness and did not identify behavioral triggers or past traumatic experiences that affected the resident. […]

• Actual harm, isolatedF760Feb 20, 2025

  Based on interview and record review, the facility failed to ensure one resident (Resident #1), in a review of three sampled residents, was free from significant medication error. Staff administered Resident #1 another resident's (Resident #3's) 8:00 A.M. scheduled medications\and then following the error, administered Resident #1's scheduled 8:00 A.M. medications. Resident #1 experienced low blood pressure, lethargy, increased weakness, and required intravenous (IV) fluids. The facility census was 78. […]