Below average — CMS composite of the measures below.
A standard survey is most likely before around September 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookfield Health Care Center during CMS and state inspections, most recent first.
A resident with COPD, chronic respiratory failure, and sleep apnea had an order for nightly CPAP with oxygen, but staff did not apply the CPAP for an extended period after the mask broke, despite a facility policy requiring immediate replacement of malfunctioning equipment. Nursing notes documented that the mask was missing or broken and that staff were awaiting replacement parts, while the treatment record repeatedly showed CPAP was not applied. During this time, the resident developed lethargy, anxiety, lower-than-normal oxygen saturation, and later was found with significantly decreased oxygen saturation and abnormal coloration, leading to transfer to the hospital, where hypercapnia was documented and linked to the lack of CPAP use. Staff interviews revealed that multiple LPNs knew the mask was broken but did not notify the physician, and there was no timely physician notification when the resident’s condition changed, despite expectations from the DON and Administrator that such changes and equipment failures be reported.
A resident with dementia and hypertension developed acute stroke-like symptoms, including facial drooping, slurred speech, and left-sided weakness. Despite these signs, the DON advised the family that hospital treatment would be limited and did not send the resident for emergency evaluation. The resident's condition declined significantly, with increased dependence for mobility and daily activities, and a later CT scan confirmed a new brain infarct. The facility failed to follow professional standards by not ensuring timely hospital assessment for the resident's acute change in condition.
The facility did not ensure an RN was on duty for at least eight consecutive hours each day and failed to maintain a full-time DON for nearly a month. Staff and administrator interviews, along with timecard reviews, confirmed multiple days with insufficient RN coverage and a prolonged vacancy in the DON position, despite a census of 25 residents.
Insufficient staffing resulted in delayed call light responses, missed restorative services, and unmet needs for several residents, including those requiring pain management, assistance with mobility, and supervision for smoke breaks. Staff and residents reported frequent delays, especially during meal times and shift changes, due to having fewer CNAs than required by the facility's own assessment.
The facility did not have a full-time on-site administrator, as required by state laws. The Assistant Administrator was acting in the administrator's role, while the actual Administrator was rarely present, being engaged in regional duties. Staff and residents were unclear about the Administrator's presence, with the Assistant Administrator being the main contact for administrative issues.
Failure to Provide Ordered CPAP Therapy and Timely Physician Notification After Equipment Failure and Change in Condition
Penalty
Summary
The deficiency involves the facility’s failure to provide ordered CPAP therapy and to notify the physician in a timely manner when a resident’s CPAP mask broke and when the resident experienced a change in condition. The resident had diagnoses of COPD, chronic respiratory failure, and sleep apnea, and physician orders directed that CPAP with oxygen be applied at bedtime with specific settings. The facility’s own CPAP policy required immediate replacement of broken or malfunctioning equipment. Documentation on the treatment administration record (TAR) beginning on 1/24/26 showed that staff did not apply the resident’s CPAP, and nursing notes on 1/25/26 and 1/26/26 indicated the CPAP mask was missing and no longer in use while awaiting a new mask. Subsequent notes on 1/27/26 and 1/28/26 documented that staff were waiting for replacement pieces and parts to repair the machine, and the TAR continued to show that CPAP was not applied on those dates. From 1/29/26 through 1/31/26, the TAR consistently showed that staff did not apply the resident’s CPAP. Nursing documentation on 1/30/26 stated the resident was not using CPAP and was awaiting a mask. In the early hours of 1/31/26, nurse notes recorded that the resident had an oxygen saturation of 91% on oxygen via nasal cannula, was lethargic, and was anxious with a recent change in mood, repeatedly asking staff if something was wrong because the resident had slept the day away and did not usually sleep like that. Additional notes that same night described the resident’s continued anxiety, concern about not sleeping normally, the need for a silicone mask that was on order, and oxygen saturation lower than normal. There was no documentation that the nurse contacted the physician regarding the broken CPAP mask or the resident’s change in condition at that time. The TAR showed that CPAP continued not to be applied on 2/1/26, 2/2/26, and 2/3/26. An email from the facility to an equipment supplier on 2/3/26 indicated the resident immediately needed a new CPAP mask and straps, and the DON requested advice on how to order a new one; the supplier responded that they did not provide CPAP supplies, and the facility then contacted its corporate office to identify the correct supplier. On 2/4/26, nursing notes documented that staff found the resident not verbally responding or behaving as normal, with slightly purple lips and fingers and an oxygen saturation of 75% on 5 liters of oxygen. Despite repositioning and assistance with oxygen intake, the saturation remained around 75%, and the nurse then contacted the physician, who ordered the resident sent to the hospital. Hospital records stated the resident had chronic respiratory failure, normally used 5 liters of oxygen and nightly CPAP, and that per facility report the CPAP had been broken for weeks, with the resident going without CPAP therapy at night for two to three weeks and being sent to the hospital with altered mental status due to hypercapnia likely associated with the CPAP malfunction. After the resident’s readmission to the facility, physician orders again directed application of CPAP at bedtime with oxygen and specified settings, but the TAR on 2/6/26 still showed staff did not apply the CPAP. The resident’s quarterly MDS later documented that the resident was cognitively intact, had no refusal of care, experienced shortness of breath when lying flat, and used oxygen therapy and noninvasive mechanical ventilation within the last 14 days of the assessment. In interviews, the resident reported having an adverse reaction from the old CPAP that resulted in hospitalization and later receiving a new mask that worked better. The ADON/LPN acknowledged that staff were unable to apply the CPAP because the mask was broken and that the resident went without CPAP for a few days. One LPN stated the mask broke, staff tried to tape it, a piece was lost so it could not be used, and although the LPN observed a change in the resident’s status on 1/31/26 and reported concerns to the DON, the LPN did not call the physician and did not recall notifying the physician about the broken mask or the change in condition. Another LPN knew the mask was broken but did not report it to the physician, citing no observed changes in daily respiratory assessment, and later was unaware that a replacement mask had arrived and did not look for it. The DON and Administrator both stated they expected staff to notify them and the physician when a CPAP mask or ordered equipment was not functioning and when a resident had a change from baseline, but the record showed this did not occur in a timely manner for this resident.
Failure to Provide Emergency Care for Resident with Stroke Symptoms
Penalty
Summary
A resident with a history of dementia, high blood pressure, and cognitive communication deficit experienced a significant change in condition, presenting with stroke-like symptoms including facial drooping, slurred speech, delayed responses, and left-sided weakness. Therapy staff and the DON observed these symptoms during therapy sessions and reported them. The DON contacted the resident's physician, initially requesting a urine sample to rule out a urinary tract infection, and later reported the full set of stroke-like symptoms. However, there was no documentation of a comprehensive assessment following the onset of these symptoms. Despite clear indications of a possible stroke, the DON advised the resident's family that hospital treatment would likely be limited due to the resident's age and suggested that the hospital could do nothing more than the facility. After this conversation, the family declined hospital transfer, and the resident was not sent for emergency evaluation. The facility's policy required immediate clinician notification and action for changes in condition, but the DON did not escalate the situation to the regional nurse until after speaking with the family, and the physician did not recall the conversation. Both the regional nurse and regional director later stated that stroke-like symptoms should have been treated as an emergency requiring hospital transfer. Following the incident, the resident experienced a marked decline in functional abilities, losing the ability to ambulate with a cane or walker, requiring increased assistance for transfers, and becoming dependent on staff for basic mobility and activities of daily living. Subsequent assessments and therapy notes documented severe left-sided weakness and mobility impairment, consistent with a stroke. A later CT scan confirmed a new area of brain infarct. The facility failed to provide care and treatment in accordance with professional standards by not ensuring timely hospital evaluation for the resident's acute neurological symptoms.
Failure to Provide Required RN Coverage and Full-Time DON
Penalty
Summary
The facility failed to provide a Registered Nurse (RN) on duty for at least eight consecutive hours each day, seven days a week, as required by policy and regulation. Review of employee timecards over a period of approximately one month revealed multiple days with either no RN coverage or less than the required eight hours of RN coverage. Specific dates were identified where RN coverage ranged from zero to just over five hours, and on some days, there was no RN present at all. Interviews with staff confirmed that there were multiple days without adequate RN coverage, and that the RN on duty did not always work the full eight hours required. Additionally, the facility did not have a full-time Director of Nursing (DON) for nearly a month. Staff interviews and facility records indicated that the DON position was vacant from one date to another, and although a corporate DON was present intermittently, this did not meet the full-time requirement. The Assistant Director of Nursing and the administrator both acknowledged the absence of a full-time DON and the lack of consistent RN coverage during this period. The facility census during this time was 25 residents.
Insufficient Staffing Leads to Delayed Care and Unmet Resident Needs
Penalty
Summary
The facility failed to provide sufficient nursing staff to meet the needs of all residents, as evidenced by multiple instances where only two CNAs were scheduled on shifts when the facility's own assessment identified the need for three. This staffing shortfall directly impacted resident care, resulting in delayed responses to call lights, missed restorative services, and the inability to accommodate scheduled smoke breaks for dependent residents. The facility's call light logs and resident interviews documented numerous occasions where call lights went unanswered for extended periods, sometimes up to 56 minutes, particularly during meal times and shift changes when staffing was especially inadequate. Several residents with significant care needs, including those with quadriplegia, contractures, chronic pain, and high dependency for activities of daily living, experienced delays in receiving assistance. For example, one resident who required pain medication reported waiting up to 40 minutes for staff to respond to their call light, often when requesting pain relief. Another resident, dependent on staff for all mobility and at risk for aspiration, did not receive regular range of motion (ROM) exercises due to the absence of a restorative program, and staff confirmed that no one was designated to provide these services. Residents and their families consistently reported dissatisfaction with the timeliness of staff response, especially during busy periods. Additionally, a resident who required a mechanical lift and staff supervision to smoke was unable to participate in scheduled smoke breaks because staff were occupied with other care duties. This resident expressed distress over missing smoke breaks and waiting long periods for assistance, with staff confirming that care priorities and limited staffing made it difficult to accommodate such requests. Staff interviews corroborated these findings, acknowledging the challenges of meeting resident needs with insufficient personnel, particularly during high-demand times. The facility's leadership also recognized the lack of adequate staffing and the absence of a restorative program, further contributing to unmet resident needs.
Facility Lacks Full-Time On-Site Administrator
Penalty
Summary
The facility failed to comply with state laws by not designating a full-time administrator who was employed in the facility. Observations revealed that the Assistant Administrator occupied the Administrator's office, and the Administrator's license was displayed, although the Assistant Administrator was acting in the administrator's role. Interviews with various staff members, including the Maintenance Director, CNA, CMT, and LPN, confirmed that the Assistant Administrator was perceived as the acting administrator, while the actual Administrator was rarely present in the facility. The Administrator was reported to be in the facility only a few times since February, primarily for meetings and rounds, and was otherwise engaged in duties as a Regional Director of Operations. Residents and staff expressed uncertainty about the Administrator's presence and role, with many indicating that the Assistant Administrator was the primary point of contact for administrative matters. The Chief Operating Officer expected the Administrator to support the facility on a full-time basis, but the Administrator admitted to being unable to fulfill this role due to responsibilities at other facilities. This lack of a full-time, on-site administrator had the potential to affect all 30 residents of the facility.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Brookfield
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Life Care Center Of Brookfield | 1.2 mi | ★★★★★ | 0 | 0 |
| Pioneer Skilled Nursing Center | 8.8 mi | ★★★★★ | 0 | 0 |
| Livingston Manor Care Center | 24.4 mi | ★★★★★ | 17 | 0 |
| Grand River Health Care | 24.7 mi | ★★★★★ | 3 | 1 |
| Morningside Center | 25 mi | ★★★★★ | 1 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.