Above average — CMS composite of the measures below.
The next survey window likely opens around May 2027
Estimate from public CMS data, current as of October 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookside Care Center during CMS and state inspections, most recent first.
Infection control practices were not followed for several residents. Three residents who met EBP criteria were not placed on EBP, with no PPE available and staff providing direct care and wound treatment without gowns or gloves. During wound care for a resident with pressure injuries and MASD, stool was present at the rectum and the NP continued the dressing change without cleaning the stool first. Staff also handled medications with bare hands for multiple residents, including breaking pills and opening a capsule by hand.
Failure to notify the Ombudsman of resident transfers: two residents were transferred to the hospital multiple times, but their names were not included on the monthly discharge list sent by the SW. The SW said the report only captured residents discharged to home and did not know hospital transfers also had to be included; the NHA confirmed the same guidance had been provided.
Missing Skin Assessment on Readmission: A resident returned from the hospital with documented venous and arterial ulcers, but the EMR did not include a skin assessment on readmission. Facility policy required a skin assessment and treatment plan, and staff interviews confirmed that admission/readmission skin assessments were expected, yet the DON and NHA were unsure whether one had been completed.
A facility failed to consistently assess and document pressure injuries and open skin areas for two residents. One resident had pressure injuries on admission and readmission, but the wounds were often recorded as one large area or as scattered full-thickness wounds without separate measurements, depth, or full wound-bed descriptions. Another resident’s coccyx MASD progressed to an unstageable PI, yet the documentation alternated between one wound and scattered wounds without identifying the number, size, or characteristics of the separate open areas.
A resident with dementia, orthostatic hypotension, hemiplegia, severe cognitive impairment, and dependence for transfers was care planned to have a floor mat beside the bed and increased supervision for fall prevention. Surveyors observed the resident in bed attempting to get out with legs hanging off the side, with no mat in place and no staff readily available, and later observed the resident again without the mat. An LPN could not locate the mat and an RN supervisor confirmed it should have been in place.
A resident with moderate cognitive impairment and excoriation disorder was prescribed olanzapine by a psych NP for repetitive skin picking of the nose and arms. The pharmacist twice noted that the antipsychotic lacked an allowable diagnosis to support its use, but the physician initialed the review without changing the diagnosis, and facility leadership later stated they were not aware of the recommendation.
A resident with multiple medical conditions and moderate cognitive impairment was mistakenly given another resident's medications, including several cardiac, antipsychotic, and diabetic drugs, after an LPN failed to properly verify the resident's identity. The error resulted in the resident becoming lethargic and requiring hospitalization.
A resident's oxycodone medication was discovered missing, but the facility did not report the suspected misappropriation to the State survey agency and delayed notifying law enforcement. Nursing staff confirmed the incident led to changes in narcotic medication handling procedures. The DON stated the State agency was not notified due to uncertainty about the missing medication, and law enforcement was only contacted after corporate advised it. The facility did not follow its own policy or regulatory requirements for timely reporting.
The facility did not thoroughly or promptly investigate and report two separate allegations: one involving a resident's missing rings and another involving missing narcotic medication. In both cases, required interviews and documentation were incomplete, and the state agency was not notified as mandated by facility policy. Family concerns about staff involvement were not fully addressed or reported, and law enforcement was only contacted after corporate intervention.
A resident with multiple chronic conditions reported foot pain, but an LPN assessed only the leg, did not remove socks, and failed to document the pain complaint or notify supervisory staff as required by policy. Later, further assessment revealed swelling and pain in the foot, and x-rays confirmed multiple metatarsal fractures. The initial lack of comprehensive assessment and documentation delayed appropriate diagnosis and care.
A resident with multiple fractures and limited mobility, who was at risk for pressure ulcers, developed a facility-acquired deep tissue injury on the right heel that progressed to an unstageable ulcer. The care plan required frequent repositioning, skin checks, and use of pressure-reducing devices, but there was no documentation that these interventions were consistently implemented or monitored. Staff interviews and record reviews confirmed the lack of evidence for required care, and the care plan was not updated as the wound deteriorated.
A facility failed to ensure proper communication with a dialysis center and did not administer a prescribed medication on dialysis days for a resident with end-stage renal disease. The resident's calcium acetate was not given on multiple occasions, and the facility did not maintain adequate communication with the dialysis center, as required by their policy. Staff interviews confirmed the medication was not administered as ordered, and documentation from the dialysis center was not consistently received or recorded.
The facility failed to complete discharge summaries for two residents, compromising continuity of care. One resident was discharged without a summary despite having discharge orders and instructions explained, while another was discharged without a nursing note or formal summary. Staff interviews confirmed the absence of required documentation.
The facility did not complete timely performance reviews for three CNAs, as required by policy. CNA 4, CNA 1, and CNA 5 all experienced delays in their annual evaluations, which were acknowledged by the DON, ADON, and Administrator as important to complete on time.
Infection Control Failures in EBP, Wound Care, and Medication Handling
Penalty
Summary
The facility did not maintain an infection prevention and control program designed to reduce the transmission of disease and infection for multiple residents. Three residents, R26, R96, and R133, met criteria for Enhanced Barrier Precautions (EBP) but were not placed on EBP. R26 had an indwelling urinary catheter, and staff were observed transferring and assisting the resident without gowns, with no PPE available in or outside the room. R96 also had an indwelling urinary catheter, yet no PPE was available in or outside the room and a CNA entered the room without PPE and assisted the resident with stockings and shoes while sitting on the resident’s bed. R133 had a pressure injury to the coccyx, but there was no EBP sign posted and no gowns or gloves available outside the room when the wound treatment was completed. During wound care for R67, who had pressure injuries to the buttocks and moisture associated skin damage with open areas, the resident was rolled for sacral treatment and had visible stool at the rectum. The NP cleaned the wound while pushing fecal matter toward the rectum, did not allow the resident to have a bowel movement at that time, did not clean the stool from the rectum, and continued the dressing change with stool still present. The dressing was then placed over the wound, and floor staff were told the resident would need assistance cleaning up after finishing the bowel movement. Medication administration practices also did not follow infection control expectations. An LPN preparing medications for R139 punched pills directly into a bare hand, placed them into a medication cup, and picked up a pill from the medication cart with a bare hand after it fell. Another LPN handling medications for R55 broke a pill in half with bare hands before administration. The same LPN also removed Florastor from R106’s medication cup with bare hands and opened the capsule to add the powder back into the cup. The facility’s medication administration policy stated medications should not be touched with bare hands, and the IP agreed the observed practices were not good infection prevention methods.
Failure to Notify Ombudsman of Resident Hospital Transfers
Penalty
Summary
The facility failed to provide notice of discharge to the Office of the State Long-Term Care Ombudsman for 2 of 4 residents reviewed for discharge from the facility. One resident was transferred to the hospital 6 times between 2/7/26 and 5/17/26, and no notice was provided to the Ombudsman for those transfers. Another resident was transferred to the hospital 2 times between 3/31/26 and 4/20/26, and no notice was provided to the Ombudsman. During interview and record review, the Nursing Home Administrator stated the Social Worker sent a monthly email to the Ombudsman with the names of residents discharged that month. The monthly discharge lists reviewed by the surveyor did not include either resident. The Social Worker stated the list was pulled from the electronic charting system and only included residents discharged to home, and stated they did not know the Ombudsman list needed to include residents transferred or discharged to the hospital. The Nursing Home Administrator also provided a document stating that federal regulations require nursing homes to provide notice of discharge to the state LTC Ombudsman Program when a resident is discharged or transferred from a facility.
Missing Skin Assessment on Readmission
Penalty
Summary
The facility did not ensure that one resident received treatment and care in accordance with professional standards of practice because no skin assessment was documented when the resident returned to the facility after a hospital stay. The resident returned on 4/9/26, and the electronic medical record did not include a skin assessment at readmission. The resident’s significant change MDS completed on 4/22/26 documented three venous and arterial ulcers present at the time of assessment, and the resident had physician orders dated 4/9/26 to apply betadine to the left lateral foot, left great toe tip, and left 2nd toe daily, with coverage for protection allowed. The facility policy titled Skin care management stated that each resident will have a skin assessment and treatment plan for maintenance of skin integrity and wound management if required. During interview, the WCN stated body assessments are completed on admission or readmission and the nurse completing admission is responsible for documenting any wounds or skin concerns and notifying the wound team. The DON stated nurses are expected to complete skin assessments on admission and when skin issues are found during weekly skin checks, but was not sure whether a skin assessment had been completed for the resident on readmission. The NHA also stated that a skin assessment is expected on admission and includes all skin alterations present at that time.
Incomplete Pressure Injury Assessment and Documentation
Penalty
Summary
The facility did not ensure pressure injuries and open skin areas were assessed and documented consistently with professional standards of practice for two residents. For one resident, the record showed pressure injuries on admission and on subsequent readmissions, but the wounds were not comprehensively assessed right away, and multiple open areas were often documented as one wound without measurements, depth, wound-bed description, or the number of separate wounds. For the other resident, moisture associated skin damage to the coccyx progressed to an unstageable pressure injury, but the documentation repeatedly described the area as a single wound or a scattered area without identifying how many open areas were present, their individual sizes, or complete wound characteristics. One resident was cognitively intact, dependent for toileting, bed mobility, and transfers, had an indwelling urinary catheter, and had an activated POA. The hospital wound consult documented deep tissue injuries to both buttocks, and the discharge summary included treatment orders. On admission, nursing documented open areas to the coccyx, right buttock, and excoriation to both buttocks, but no comprehensive wound assessment with measurements or wound descriptors was documented and no treatment was obtained for the coccyx area. Later documentation alternated between MASD, Stage 2, and Stage 3 pressure injuries, with several notes describing scattered full-thickness wounds over large areas without identifying the individual wounds or measuring them separately. Surveyor observation also found active bleeding when barrier cream was removed, and the wound practitioner stated there were three wounds, but the individual open areas had not been measured because the practitioner did not want to document that the resident had three wounds. The second resident had elected hospice services and initially had blanchable redness to the coccyx, for which hospice was notified and Calmoseptine was ordered. The record then documented two open areas, but subsequent wound documentation described MASD to the coccyx as a single area, then an unstageable pressure injury, and later as scattered full-thickness wounds with slough and epithelial tissue without describing the number, appearance, or locations of the separate wounds. On surveyor observation, the wound had defined edges and measured approximately 1.5 cm x 1.5 cm x 0.2 cm with 100% slough, while the practitioner’s documentation continued to describe the area in broad terms rather than documenting the separate open areas noted earlier.
Failure to Maintain Fall Mat and Supervision for a High-Fall-Risk Resident
Penalty
Summary
The facility did not ensure adequate supervision and safety to prevent accidents for a resident who was at risk for falls and was care planned to have a floor mat alongside the bed. The resident was admitted with diagnoses including dementia, orthostatic hypotension, hemiplegia, and hemiparesis affecting the right dominant side. The resident’s MDS indicated severe cognitive impairment, no impairment in the upper or lower extremities, and dependence for transfers from bed to chair. The care plan identified fall risk interventions including assessment and treatment for postural/orthostatic hypotension, call light within reach, a floor mat next to the bed while in bed, an exercise program, increased staff supervision, medication review, and individualized toileting interventions. Surveyors observed the resident in bed with both legs hanging off the side and attempting to get out of bed, appearing close to sliding out of bed, while no floor mat was in place and no staff were readily available. A CNA was later found and assisted the resident back into bed. On a later observation, the resident was again seen in bed without a floor mat next to the bed. An LPN reviewed the care plan, confirmed that a fall mat should be in place, and was unable to locate one in the room. The LPN stated she was unsure why the mat was not in place and said she would get one for the resident. The RN Supervisor later confirmed the resident should have had a fall mat in place and stated a mat had now been provided.
Pharmacist Drug Review Irregularity Not Addressed for Antipsychotic Use
Penalty
Summary
The facility did not ensure that a licensed pharmacist’s monthly drug regimen review irregularity was addressed by the attending physician for one resident, R5, who was reviewed for unnecessary medications. R5 had moderate cognitive impairment with a BIMS score of 10 and had been seen by a psychiatric NP for major depressive disorder, generalized anxiety disorder, insomnia, and excoriation (skin-picking) disorder. The NP documented repetitive skin picking of the nose and arms, reported by R5, the spouse, and facility staff, and ordered olanzapine 2.5 mg daily to treat the disorder. On the pharmacist’s 2/6/26 review, the pharmacist documented that R5 was receiving Zyprexa (olanzapine) but lacked an allowable diagnosis to support its use and provided a list of appropriate diagnoses to the physician. The document was initialed by the physician, but no changes were made to the diagnosis connected to olanzapine. The same irregularity was identified again on 5/11/26, with no change to the diagnosis. During surveyor interviews, ADON-K stated they were not aware of the recommendation, and MD-U stated the diagnosis should be dementia with behaviors and described R5 as picking the face and arms until they bled.
Significant Medication Error Due to Failure to Verify Resident Identity
Penalty
Summary
A significant medication error occurred when a resident with multiple complex medical conditions, including diabetes with chronic kidney disease, acute respiratory failure, and moderate cognitive impairment, was administered another resident's medications. The medications given included amiodarone, bumetanide, carvedilol, clozapine, divalproex, Jardiance, and lamotrigine. The facility's policy required staff to verify the resident's identity using a photo in the electronic medical record and by asking the resident's name, as well as to follow the six rights of medication administration. The error took place when an LPN, preparing to administer medications, mistook one resident for another after a resident approached the medication cart and asked for medication. The LPN engaged in conversation, took vital signs, and administered the medications intended for a different resident without properly verifying the resident's identity. The mistake was discovered when the actual intended recipient was later brought to the unit, prompting the LPN to realize the error after checking the medication drawer and confirming the wrong resident had received the medications. Following the administration of the incorrect medications, the affected resident became lethargic, was unable to respond verbally, and exhibited slow, shallow respirations with drooling. Vital signs were taken, and emergency services were called. The resident was transported to the hospital for further care. The incident was documented in the resident's progress notes, and the LPN involved provided a written statement describing the sequence of events that led to the error.
Failure to Timely Report Suspected Misappropriation of Narcotic Medication
Penalty
Summary
The facility failed to report a suspected incident of misappropriation of a resident's narcotic medication to the State survey agency and delayed notification to law enforcement. The incident involved a missing card of oxycodone prescribed to a resident, which was discovered on 02/12/2025. Facility policy requires that all allegations of abuse, neglect, exploitation, mistreatment, and misappropriation of resident property be reported to the appropriate authorities within specified timeframes, including immediate notification to supervisors and reporting to the State agency within 24 hours if the event does not involve abuse or serious bodily injury. Despite being made aware of the missing medication, the facility did not notify the State agency at any point and only notified law enforcement on 02/28/2025, more than two weeks after the discovery. Interviews with nursing staff confirmed that the incident led to changes in procedures for narcotic medication counts, including performing counts in the medication room in front of a camera. The Director of Nursing acknowledged that the State agency was not notified because there was uncertainty about whether the medication was actually missing, and the facility was still investigating the allegation at the time. The facility's investigation documented that the resident's oxycodone card was last signed in on 01/31/2025, with the last dose given on 02/06/2025, and the card discovered missing on 02/12/2025. All staff who worked during the relevant timeframe tested negative for drug use. The delay in reporting the incident to law enforcement was attributed to a suggestion from the facility's corporate office. The surveyor found that the facility did not follow its own policy or federal and state requirements for timely reporting of suspected misappropriation.
Failure to Timely and Thoroughly Investigate and Report Allegations of Misappropriation and Medication Diversion
Penalty
Summary
The facility failed to ensure that allegations of misappropriation and potential medication diversion involving two residents were thoroughly and timely investigated, as required by facility policy. In the first case, a resident with a diagnosis of dementia and a BIMS score indicating cognitive intactness reported missing engagement and wedding rings. The facility initiated a self-report but did not document interviews with other residents on the unit regarding missing items. Although the resident's family expressed suspicion that a newly hired staff member was involved, this information was not submitted to the state agency, nor was an addendum made to the original self-report. The facility did not re-interview the staff member in question or document further investigation into the family's concerns. In the second case, staff reported missing medications for another resident, but the facility did not submit the allegations of potential misappropriation to the state agency. Interviews with nursing staff revealed that after the incident, procedures for narcotic medication counts were changed, and re-education was provided. However, the facility did not report the missing medication to the state agency within the required timeframe, as the DON stated uncertainty about whether the medication was actually missing and indicated the investigation was ongoing. Law enforcement was only notified after corporate direction, and the state agency was not informed within five working days as required. The facility's policy on abuse, neglect, misappropriation, exploitation, and mistreatment requires immediate initiation of investigations and prompt notification of the administrator or designee when such allegations arise. In both cases, the facility did not follow its own policy for timely and thorough investigation or for reporting to the appropriate authorities. Documentation was incomplete, and key steps in the investigative process were omitted, leading to deficiencies in the facility's response to alleged violations.
Failure to Assess and Document Resident's Pain Complaint Resulting in Delayed Fracture Diagnosis
Penalty
Summary
A deficiency occurred when a resident with multiple complex diagnoses, including Multiple Sclerosis, dementia with behavioral disturbance, severe osteopenia, and right foot drop, did not receive a comprehensive assessment or appropriate documentation after initially complaining of foot pain. On the morning of the incident, the resident cried out and reported foot pain to a CNA, who then notified an LPN. The LPN assessed the resident's leg instead of the foot, did not remove the resident's socks, and did not document a pain assessment or progress note regarding the complaint. The LPN also did not notify the nurse supervisor, as required by facility policy, and there was no evidence that the pain complaint was communicated during shift change. Later that day, the resident again complained of foot pain to staff, and upon further assessment by another LPN, swelling and pain to the left foot and toes were noted. An x-ray was ordered, revealing fractures in the 3rd, 4th, and 5th metatarsals of the left foot. The resident was sent to the hospital for evaluation and returned with a cast and ACE wrap. Review of the medical record showed no documentation of the initial pain complaint, no comprehensive assessment, and no pain assessment completed at the time of the first report of pain. Interviews with staff revealed inconsistencies in the communication and assessment process. The CNA who first reported the pain stated it was the foot that hurt, while the LPN recalled being told it was the leg. The LPN admitted to not assessing the foot or toes and not documenting the event, only assessing the leg and finding no pain. The nurse supervisor and DON confirmed that the facility's policy required a comprehensive assessment and documentation for any new pain complaint, regardless of whether the resident continued to report pain at the time of assessment. The lack of a thorough assessment and documentation led to a delay in identifying the resident's fractures.
Failure to Prevent and Monitor Pressure Ulcer Development
Penalty
Summary
A resident was admitted to the facility with multiple fractures and a history of a stage II pressure ulcer to the sacrum, but no skin issues on the right heel. The resident was assessed as being at risk for further pressure ulcer development and required extensive assistance for mobility and personal care. The care plan included interventions such as frequent repositioning, skin checks, use of pressure-reducing devices, and elevation of the heels when in bed. However, there was no documented evidence that these interventions were consistently implemented or monitored as required by the care plan and facility policy. Over the course of the resident's stay, documentation failed to show that staff performed regular skin checks, floated the resident's heels, or repositioned the resident frequently. The electronic medical record and point of care documentation did not reflect that the ordered interventions, such as the use of a heel boot and tubi grips, were carried out. The resident subsequently developed a deep tissue injury (DTI) to the right heel, which later deteriorated to an unstageable pressure ulcer. The care plan was not updated to reflect the deterioration of the wound or to include new interventions in response to the change in the resident's condition. Interviews with staff, including CNAs and RNs, revealed that they did not recall the resident or specific care provided, and the Director of Nursing was unable to provide documentation that the required interventions were completed. The lack of documentation and failure to implement and monitor the prescribed interventions led to the development and worsening of a facility-acquired pressure ulcer on the resident's right heel.
Failure in Dialysis Care Coordination and Medication Administration
Penalty
Summary
The facility failed to ensure proper communication and collaboration with the dialysis center and did not administer a prescribed medication on dialysis days for a resident with end-stage renal disease. The resident, who was cognitively intact, was admitted with diagnoses including end-stage renal disease and type two diabetes mellitus, and was dependent on renal dialysis. The resident had an order for calcium acetate to be administered once daily, specifically around lunchtime, to manage chronic kidney disease. However, the facility did not administer the calcium acetate on dialysis days, as evidenced by the Medication Administration Record (MAR) showing missed doses on multiple occasions in September, October, and November. The nursing staff coded these missed doses as the resident being out of the facility for dialysis, despite there being no physician order to hold the medication during these times. Interviews with facility staff, including an LPN and the Registered Nurse Supervisor, confirmed the medication was not given as ordered on dialysis days. Additionally, the facility did not maintain adequate communication with the dialysis center. The facility's policy required collaboration with the dialysis center to ensure coordinated care, including sharing vital information such as vital signs and weights. However, the facility only documented the resident's vitals before leaving for dialysis and did not consistently receive or document information from the dialysis center. The Director of Nursing and Assistant Director of Nursing acknowledged the lack of documentation and communication, which was only addressed upon request during the survey.
Failure to Complete Discharge Summaries for Residents
Penalty
Summary
The facility failed to ensure that discharge summaries were completed for two residents, R393 and R140, prior to their discharge, which is necessary to ensure continuity of care. For R393, the electronic medical record indicated that discharge orders and medication lists were sent to the Physician Assistant, and discharge instructions were explained to the resident and their Power of Attorney. However, there was no evidence of a discharge summary being provided to the resident or their representative. For R140, the records showed that the resident was admitted with a diagnosis of a lumbar vertebra fracture and was discharged to an assisted living facility. Despite the discharge being planned, there was no discharge note written by nursing staff on the date of discharge. Interviews with the Director of Nursing and Registered Nurse confirmed the absence of a discharge note and indicated that the facility does not complete formal discharge summaries. The Social Services Director also confirmed that the instructions given at discharge only included a list of current medications, home health information, and scheduled appointments, without a recapitulation of the resident's stay.
Delayed Performance Reviews for CNAs
Penalty
Summary
The facility failed to ensure that performance reviews were completed for three out of five Certified Nurse Aides (CNAs) within the required 12-month period. According to the Nursing Staff Competency Policy, each CNA should receive a performance review at least once every 12 months. However, CNA 4, who started on 09/24/21, did not have a timely review, as her last review was dated 09/23, and the evaluation should have been completed by 09/24/24. Similarly, CNA 1, who began employment on 02/03/19, had her last review on 02/28/23, with the document signed on 05/07/24, indicating a delay. CNA 5, with a start date of 02/11/16, also had a delayed review, with the last one dated 02/26/23 and signed on 05/07/24. During interviews, the Director of Nursing (DON), Assistant DON (ADON), and the Administrator acknowledged the importance of completing annual performance reviews on time.
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Illustrative
What surveyors actually found near you
We read the 414 citations issued within 25 miles in the last 12 months — including the 13 immediate-jeopardy cases — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
A prioritized, do-first checklist
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Illustrative
Risk indicators are statistical estimates from public CMS data — not predictions, findings, or compliance advice.
Nursing homes near Kenosha
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avina Of Kenosha | 0.3 mi | ★★★★★ | 1 | 0 |
| Waters Edge Health And Rehabilitation Center | 1.6 mi | ★★★★★ | 2 | 0 |
| Clairidge House | 2 mi | ★★★★★ | 29 | 0 |
| Avina On 32nd | 3.7 mi | ★★★★★ | 19 | 0 |
| Sheridan Health And Rehabilitation Center | 3.8 mi | ★★★★★ | 33 | 0 |
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