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F0908
F

Failure to Ensure Facility-Wide Security Alarm Notification

Brookfield, Wisconsin Survey Completed on 05-08-2025

Penalty

No penalty information released
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The penalty, as released by CMS, applies to the entire inspection this citation is part of, covering all citations and f-tags issued, not just this specific f-tag. For the complete original report, please refer to the 'Details' section.

Summary

Surveyors observed that the facility failed to ensure its security alarm system was capable of alerting staff throughout the entire building when triggered. On the morning of the survey, two surveyors entered the facility through an unlocked front entrance, which activated a loud screeching alarm near the entrance and a beeping sound with visual indicators at the One South nursing station. However, as the surveyors moved further into the building, the alarm became less audible and was not heard at the One East/West nursing station or on the second floor. Staff present in these areas, including a CNA and an RN, confirmed they could not hear the alarm when it was triggered. Interviews with facility leadership and staff, including the Maintenance Director, Facility Administrator, DON, Director of QA, and CIO, confirmed that the alarm system only provided audible and visual notifications at the One South nursing station and did not communicate alerts to other critical care areas. The system was not monitored by a security company, and information about alarm activations was not relayed to other units. The Director of QA acknowledged the need for an alarm system that could notify all critical care areas, particularly beyond the One South nursing station.

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