Aria of Brookfield: Untreated Toe Wound for Days - WI
The resident, identified as R97 in inspection records, was readmitted to the facility with a pressure injury on their right fifth toe that required daily wound care with specialized honey and silver dressings. But nursing staff entered the treatment as "PRN" — meaning as needed — rather than as a daily scheduled order.
No treatment was documented as completed until July 2, days after the resident's readmission.
The physician had ordered specific wound care: cleanse with normal saline, apply medihoney and calcium alginate with silver, followed by a foam border dressing, to be performed daily and as needed. The facility's treatment administration record for June 2025 shows this order listed only under PRN treatments, with no daily scheduled care documented.
During those untreated days, the wound worsened. When a wound specialist finally assessed the injury on July 2, they found it measured 1 centimeter by 1.3 centimeters by 0.3 centimeters deep. Sixty percent of the wound showed healthy granulation tissue, but 30 percent remained necrotic — dead tissue that can harbor infection. Ten percent exposed tendon underneath.
The specialist had to surgically debride the wound, cutting away dead tissue that had accumulated during the treatment gap.
Federal inspectors observed the facility's wound nurse performing proper treatment on August 27, finding no concerns with the actual care provided. But the documentation failures revealed a breakdown in the admission process that left the resident without needed medical treatment.
When inspectors questioned the wound nurse about who handles treatment orders for newly admitted residents, she explained that either she or another wound nurse typically enters the orders. If wound nurses aren't available, the admitting nurse handles it.
The wound nurse initially told inspectors she would "look into" the documentation problem. When questioned again later that day, she acknowledged placing the treatment order on June 30 but admitted understanding the concern.
"The treatment order should have been ordered and placed in the TAR on 6/27/25 and treatment should have been completed," she told inspectors.
The resident's care plan, dated May 6, called for multiple pressure-relieving measures including an alternating pressure mattress, heel offloading boots, and regular turning and positioning. The plan specifically directed staff to "follow facility protocols for treatment of injury."
But those protocols failed during the critical first days after readmission.
By August 21, after weeks of proper treatment, the wound had significantly improved. It measured just 0.8 centimeters by 1 centimeter by 0.1 centimeters deep, with 100 percent healthy granulation tissue. Treatment was reduced to three times weekly with a different dressing protocol.
The case illustrates how administrative errors can directly impact resident health outcomes. Pressure injuries on the feet are particularly dangerous for elderly residents, who often have compromised circulation and healing. Untreated wounds can quickly develop serious infections, potentially leading to amputation or life-threatening sepsis.
The inspection found the facility caused "actual harm" to residents through this violation, meaning the inadequate care resulted in measurable negative health outcomes rather than just potential risk.
Federal regulations require nursing homes to ensure residents receive treatment and care in accordance with professional standards of practice. The failure to implement physician orders as written violated those standards and delayed healing for a vulnerable resident.
The wound eventually healed with proper treatment, but only after days of neglect that required surgical intervention to remove dead tissue that accumulated while the injury went untreated. The resident endured unnecessary pain and faced increased infection risk because of clerical failures in the facility's treatment ordering system.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Aria of Brookfield from 2025-08-27 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
Aria of Brookfield in BROOKFIELD, WI was cited for violations during a health inspection on August 27, 2025.
But nursing staff entered the treatment as "PRN" — meaning as needed — rather than as a daily scheduled order.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.