BROOKFIELD, WI - A federal complaint investigation at Brookfield Rehab and Specialty Care Center revealed significant staffing deficiencies during the weekend of January 25-26, 2025, with facility leadership acknowledging they operated below their own minimum staffing requirements while residents experienced extended wait times for basic care needs.
Facility Operated Below Minimum Staffing Standards
Federal surveyors documented that the facility failed to maintain its established minimum staffing levels during the final weekend of January 2025. According to staffing criteria provided by the facility's scheduler, the nursing home required 10 certified nursing assistants (CNAs) for census levels, with five assigned to each floor during morning and evening shifts.
Posted schedules for January 25 showed only eight CNAs working the morning shift, six on the evening shift, and four during the overnight hours. The following day, January 26, staffing dropped to seven CNAs in the morning, nine in the evening, and five overnight - all below the facility's documented requirements.
When questioned about the staffing discrepancies, the scheduler indicated she was only "allowed" four CNAs upstairs and five downstairs for that weekend, totaling nine CNAs rather than the required 10. However, she could not provide written communication documenting this authorization at the time of the inspection.
Licensed nursing staff numbers also fell short of requirements. The facility's staffing criteria called for six nurses during morning and evening shifts and three during nights. On January 25, only five licensed staff worked the morning shift, four during evening hours, and two overnight.
Residents Left Waiting Hours for Basic Needs
The staffing shortages had direct consequences for resident care. Multiple residents and family members reported significant delays in receiving assistance throughout the weekend.
One resident stated they waited "a couple of hours at times" to receive help when using the call light system. Another resident described wait times ranging from 30 minutes to two hours, adding that staff routinely explained they were short-staffed when they finally arrived.
A certified nursing assistant working that weekend confirmed to investigators that the facility had only three CNAs during one morning shift. The aide explained that with so few staff members, residents received assistance on a "first come, first serve basis" and that some residents "waited a lot longer than 10 minutes" before staff could reach them. The aide noted that completing a full bed bath requires at least 10 minutes per resident, creating a cascade of delays when multiple residents need simultaneous assistance.
Adequate staffing in nursing homes is essential for timely response to resident needs. When call lights go unanswered for extended periods, residents face increased risks of falls, prolonged exposure to incontinence leading to skin breakdown, inadequate hydration, and missed medications. The situation becomes particularly concerning for residents with cognitive impairment or limited mobility who cannot address their own basic needs.
Family Reports 90-Minute Delay in Responding to Soiled Resident
One of the most concerning incidents involved a resident with dementia who family members found wet and in an uncomfortable position on January 26. The family member flagged down a staff member and reported the resident needed changing, but no one responded.
After waiting with the resident, the family member made five phone calls to the facility with no answer from staff. The family ultimately called an off-duty nurse's personal number, who then contacted the facility and arranged for someone to provide care. According to the family member's account, at least 90 minutes elapsed before the resident received assistance.
The family member reported leaving the facility with concerns because the resident appeared "very unsteady and confused," and there didn't seem to be enough staff available to monitor the resident. Later that same day, the resident experienced a fall.
Extended exposure to incontinence creates multiple health risks for nursing home residents. Moisture against skin breaks down the protective barrier, increasing vulnerability to pressure injuries and infections. For residents with limited mobility who cannot reposition themselves, the risk compounds significantly. Additionally, residents with dementia may not be able to communicate their discomfort or need for assistance, making timely staff rounds essential for identifying care needs.
Feeding Supervision Compromised by Staff Shortages
Another resident requiring supervision during meals reported that CNAs would leave during feeding to answer other residents' call lights. The resident's family expressed concern that this practice created safety risks, particularly given the resident's swallowing difficulties and need for close monitoring.
The resident's care plan documented requirements for supervision during meals due to cerebrovascular accident (stroke) affecting the ability to chew and swallow safely. The plan specifically included monitoring and documentation of chewing and swallowing abilities, with instructions to obtain speech therapy evaluation if problems emerged.
When staff must choose between supervising a resident at risk for choking and responding to call lights from other residents, both situations present potential safety concerns. Residents with dysphagia (swallowing difficulty) can experience aspiration - food or liquid entering the airway - which can lead to choking or aspiration pneumonia. Continuous supervision allows staff to identify signs of swallowing difficulty immediately and intervene before a medical emergency develops.
Administrator Blamed Staff Birthday Party
When investigators questioned facility leadership about the staffing shortages, the Assistant Director of Nursing explained that a staff member hosted a "big birthday party" that many off-duty CNAs attended, making it difficult to recruit workers for vacant shifts.
The facility's protocol for addressing call-ins included offering bonuses, food, and meals to encourage staff to work additional shifts. However, these incentives proved insufficient during the weekend in question.
Leadership indicated they were working to address staffing challenges through increased hiring bonuses, expanded orientation opportunities, and advertising for new employees. The Assistant Director of Nursing reported seeing an increase in interviews for CNA positions.
When asked about agency staffing, the Assistant Director confirmed the facility did not utilize temporary agency staff to fill gaps in the schedule.
Conflicting Information About Staffing Requirements
The investigation revealed inconsistencies in how staffing requirements were communicated and applied. The scheduler initially stated that staffing patterns came from corporate headquarters via email before each schedule. However, when asked to provide the email authorizing reduced staffing for January 25-26, the scheduler indicated she had not received updated staffing pattern information yet.
In a follow-up interview, the scheduler confirmed she was still using the original staffing pattern document provided to investigators, despite earlier statements suggesting corporate had approved lower staffing levels for that specific weekend. The scheduler attributed the shortfall to unavailable staff, stating "you can't make staff come in when they are busy."
This disconnect between documented staffing requirements and actual implementation raises questions about oversight and accountability. Federal regulations require nursing homes to provide sufficient staffing to meet residents' needs based on comprehensive assessments and care plans. Facilities must be able to demonstrate how they determine appropriate staffing levels and what systems are in place to ensure those levels are maintained.
Additional Violations Documented
Beyond staffing concerns, the inspection identified failures in behavioral health services, pharmaceutical services, dietary accommodations, and infection control practices.
One resident with multiple psychiatric diagnoses including vascular dementia, major depressive disorder, anxiety disorder, and histories of alcohol dependence and opioid abuse did not receive comprehensive behavioral health services despite escalating behaviors. The facility failed to conduct interdisciplinary team analysis of behavior changes or develop person-centered interventions.
In pharmaceutical services, investigators found that a discharged resident was sent home with three bubble packs of discontinued medications that should have been returned to the pharmacy. Another resident received scheduled medications late - beyond the facility's one-hour window - on 22 separate occasions during November 2024.
Dietary violations included a resident not receiving multiple items listed on their meal ticket, including a prescribed nutritional supplement essential for their renal diet and wound healing.
Infection control observations documented improper hand hygiene during incontinence care and wound treatments, along with an administrator entering a COVID-19 isolation room without required personal protective equipment.
Regulatory Context
Federal regulations require nursing homes to have sufficient nursing staff with appropriate competencies and skills to provide nursing and related services to ensure resident safety and help each resident achieve the highest practicable physical, mental, and psychosocial well-being. Staffing must be determined based on resident assessments and individual care plans, considering the number, acuity, and diagnoses of the facility's resident population.
The Centers for Medicare & Medicaid Services conducts inspections in response to complaints and during routine surveys to ensure nursing homes comply with federal health and safety standards. Facilities found in violation must submit plans of correction detailing how they will address deficiencies and prevent recurrence.
The January 29, 2025 complaint investigation resulted in multiple deficiency citations. The facility is required to develop and implement corrective action plans addressing each identified violation.
Brookfield Rehab and Specialty Care Center is located at 18740 W Bluemound Road in Brookfield, Wisconsin. The facility provides skilled nursing care and rehabilitation services.
For complete details about this inspection and the facility's plan of correction, the full report is available through the Centers for Medicare & Medicaid Services.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Brookfield Rehab and Specialty Care Ctr from 2025-01-29 including all violations, facility responses, and corrective action plans.
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