Brookfield Rehab And Specialty Care Ctr

F-F839. Enter number of staff needed or an average or range.

Total number of staff on duty each day (on average based on census).

Licensed nurses providing direct care: 13.

Nurse aids: 23.

On 1/29/25, at 12:32 PM, Scheduler-O provided Surveyor with the staffing criteria currently used by the facility. The staffing criteria documents:

Staffing.

We noticed going through schedules that there are some days we are pre booking to be over. Please see below.

* Sunday night, 4 nurses. Need 3.

* Sunday AM. 12 aides on. Need 11.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 25 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 * 7 aides on Tuesday nights need 6.

Level of Harm - Minimal harm or Please make these corrections now so we do not overbook our schedules. potential for actual harm Below is what we should be scheduling for all intensive [SIC] purposes. Residents Affected - Some 6 nurses AM/PM.

3 nurses on nights.

5 aides non dialysis nights Monday, Wednesday, Friday, Saturday.

6 aides on dialysis nights Sunday, Tuesday, Thursday.

10 aides for 103 and under. Five each floor.

No shower aide on schedule.

All above excludes orientation. No exceptions unless approved by corporate (First name of person).

Any changes to this will be census related. If you feel we need to change, please call me to discuss.

I truly hope this helps clear up the staffing expectation moving forward.

On 1/28/25, at 12:32 PM, Surveyor interviewed Scheduler-O regarding the staffing patterns for the facility.

Surveyor inquired what is the protocol for residents and family able to do if they have a concern over the staffing on a weekend. Scheduler-O informed Surveyor they can let the nurse know and the nurse will call

the Manager on-call for instructions on what they should do.

Surveyor asked Scheduler-O how staffing patterns are communicated to the scheduler. Scheduler-O informed Surveyor that staffing patterns are emailed to Scheduler-O before each schedule by corporate. Surveyor asked Scheduler-O to see the email with the expected staffing patterns for the weekends especially for the weekend of 1/25/25-1/26/25. Scheduler-O informed Surveyor the staffing pattern is the same for weekends and weekdays. Scheduler-O informed Surveyor the only difference in the schedule is when we have dialysis days, the night shift gets those residents up, so we have more staff on those nights prior to dialysis.

Surveyor asked if the staffing number documented on the daily posted staffing sheet for 1/25/25 showing 8 total certified nursing assistants (CNA) on the 6:30Am-2:30PM shift, 6 total nursing assistants on the PM shift, with one (CNA) working till 08:30 PM and 2 (CNAs) not starting the shift till 03:00PM on the 02:30PM-10:30PM shift, and 4 total nursing assistants on the night shift 10:30PM-6:30AM was correct. Scheduler informed Surveyor the posted schedule was correct.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 26 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Surveyor asked the staffing number documented on the daily posted staffing sheet for 1/26/25 showing 7 total certified nursing assistants on the AM shift, 9 total nursing assistants with one (CNA) working till 07:00 Level of Harm - Minimal harm or PM and 2 (CNAs) not starting the shift till 03:00PM on the 02:30PM-10:30PM shift, and 5 total nursing potential for actual harm assistants on the night shift was correct. Scheduler informed Surveyor that posted schedule is correct also.

Residents Affected - Some Surveyor asked Scheduler-O the reason the CNA numbers were below the 10 CNA's shown as minimum staffing levels for 1/25/25 and 1/26/25. Scheduler-O informed Surveyor that's what Scheduler-O was allowed for this weekend, 4 CNAs upstairs and 5 downstairs for the AM and PM shift, totaling 9 CNAs. Surveyor asked Scheduler-O for the communication telling Scheduler-O she was only allowed 4 CNAs upstairs and 5 downstairs for AM and PM shift the weekend of 1/25/25 -1/26/25. Scheduler-O informed Surveyor she didn't have that updated e-mail yet. Surveyor asked Scheduler-O how Scheduler-O knew what the staffing patterns were supposed to be if it wasn't E-mailed to her as stated earlier. Scheduler-O stated that corporate had informed Scheduler-O what the staffing patterns were to be. Surveyor asked for a name and phone number of the person in corporate that determined the staffing patterns for 1/25/25 and 1/26/25. Scheduler-O informed Surveyor that the corporate person was Nursing Home Administrator (NHA)-A.

Surveyor asked Schedule-O why there was less than 9 total CNAs working the weekend of1/25/25 and 1/26/25. Scheduler-O told the Surveyor there were staff call-ins and that the Manager on call would handle that. Surveyor asked Scheduler-O about the licensed nursing numbers and why they were lower than the minimum number on the form Scheduler-O gave the Surveyor. Surveyor pointed out that on 1/25/25 there were 5 licensed staff on the AM shift, 4 licensed staff on the PM shift and 2 licensed staff on the night shift. Surveyor pointed out that on 1/26/25 there were 4 licensed staff on the PM shift and 5 on the night shift.

Scheduler-O informed Surveyor the facility can't make staff work if they don't want to. Surveyor asked Scheduler-O who the manager on call for the weekend was. Scheduler-O informed Surveyor that the manager on call was Assistant Director of Nursing (ADON)-C.

On 1/29/25, at 01:53 PM, Surveyor interviewed Scheduler-O as a follow up on the new staffing patterns Scheduler-O told Surveyor Scheduler-O was waiting to be sent to her.

Surveyor asked Scheduler-O about the discrepancy between the staffing form given to the Surveyor by Scheduler-O and the Staffing the Scheduler-O was told she could have for the weekend of 1/25/25-1/26/25. Scheduler-O told Surveyor she requested the new staffing patterns from corporate, but Scheduler-O had not yet received the new staffing pattern E-Mail from corporate. Surveyor asked Scheduler-O if that new staffing pattern came from corporate or NHA-A. Scheduler-O informed Surveyor that the new staffing patterns came from corporate and not NHA-A. Surveyor showed Scheduler-O the staffing form that Scheduler-O gave to the Surveyor. Surveyor asked Scheduler-O if the communication scheduler-O gave Surveyor was the staffing pattern Scheduler-O was using currently for the facility's scheduled staffing requirement.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 27 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Scheduler-O informed Surveyor that the current staffing requirement information Scheduler-O is using is the previous staffing pattern provided to Surveyor. Scheduler-O told Surveyor that Scheduler-O did not receive Level of Harm - Minimal harm or the new staffing requirement information yet. Surveyor asked Scheduler-O if the facility was short of staffing potential for actual harm requirements routinely. Scheduler-O told Surveyor that the facility it was not normally short staffed but that

the facility just didn't have any staff that weekend. Scheduler-O informed Surveyor you can't make staff come Residents Affected - Some in when they are busy.

On 1/29/25, at 02:00PM, Surveyor interviewed ADON-C about the weekend staffing on 1/25/25-1/26/25.

Surveyor asked ADON-C if she was the on-call manager for the weekend of 1/25/25-1/26/25. ADON-C informed the Surveyor she was the on-call manager. ADON-C informed the Surveyor that ADON-C came in

on 1/25/25 to offer some assistance. Surveyor noted that ADON-C was using a knee rest scooter for her foot

in a surgical boot. Surveyor showed ADON-C the staffing pattern form given to Surveyor by Scheduler-O. Surveyor asked ADON-C if ADOC-C was aware of this staffing communication and if they were consistently below the 5 stated on this communication paper.

ADON-C informed Surveyor that ADON-C was aware of the staffing communication given to Surveyor by Scheduler-O. Surveyor asked ADON-C if the facility was below the required staffing pattern for the weekend

on 1/25/25-1/26/25. ADON-C informed Surveyor the facility was below the 5 CNAs on each floor on the weekend of 1/25/25-1/26/25. ADON-C informed Surveyor that these patterns were adjusted by corporate. Surveyor asked ADON-C if ADON-C could show Surveyor the new staffing requirements. ADON-C informed Surveyor that Scheduler-O would provide Surveyor with the updated staffing numbers.

Surveyor asked ADON-C what the normal protocol was when they have staff call-in. ADON-C informed Surveyor, the facility will offer bonuses, food, buy meals for staff so that they could come in to work. Surveyor asked if this was effective in mitigating staffing shortages. ADON-C told Surveyor normally yes, but this weekend was harder to fill because a staff member had a big birthday party that most of the off-duty Certified Nursing Assistants went to. Surveyor asked ADON-C if the facility used agency staff. ADON-C informed Surveyor the facility did not use agency staff.

Surveyor asked ADON-C, what projects, or quality improvement ideas being worked on to help alleviate

these staffing discrepancies. ADON-C informed the Surveyor that the facility was offering more hiring bonuses and more orientation opportunities for new staff. The facility was advertising for new employees and was currently seeing an increase in interviews for CNA positions.

Surveyor asked ADON-C what the protocol for residents and their families if they have concerns with staffing. ADON-C informed the Surveyor they can call the manager on call or get a hold of a nurse to call one of the managers. ADON-C informed the Surveyor the facility is working very hard to fix the staffing concerns.

On 1/28/25, at 1149 AM, Surveyor interviewed Certified Nursing Assist (CNA)-III concerning staffing levels

on 1/25/25/ and 1/26/25.

Surveyor asked CNA-III if CNA-III told a resident that staffing was very short handed the weekend on 1/25/25 and 1/26/25. CNA-III informed Surveyor that the facility was very short staffed the weekend of 1/25/25 and 1/26/25. CAN-III stated that the facility only had 3 CNAs from 6:30 AM to 2:30 PM.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 28 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Surveyor asked CNA-III if she felt it impacted the call-light answering times. CNA-III informed Surveyor that

the facility didn't have enough people to get to all the residents. CNA-III stated that residents were Level of Harm - Minimal harm or complaining, and that CNAs had trouble toileting people. CNA-III stated that residents received assistance potential for actual harm on a first come, first serve basis as the facility was short staffed. CNA-III informed Surveyor that staff did get to everyone eventually, but it is 10 minutes minimum just to do a full bed bath, and that some residents Residents Affected - Some waited a lot longer than 10 minutes before we could get to them. CNA-III informed Surveyor that during the weekend, one day the facility had only 3 aides, and that the staff can't do it with 3 CNAs only as the facility must have 4 aides to give the residents proper cares. Surveyor asked CAN-III if CNA-III could give an idea of how long residents had to wait. CNA-III informed Surveyor CAN-III couldn't say, but it was a quite a while for some.

On 1/28/25, at 09:14 AM, Surveyor interviewed Anonymous-PPP about staffing concerns for 1/25/25/-1/26/25.

Surveyor asked Anonymous-PPP if they had any problems with staff answering call lights this past weekend 1/25/25-1/26/25. Anonymous-PPP informed Surveyor when staff had time they answered the lights, and that Anonymous-PPP waited a couple of hours at times to receive assistance Anonymous-PPP informed Surveyor that they wouldn't recommend the facility to anyone.

On 1/28/25, at 01:30 PM, Surveyor interviewed Resident R22 about staffing the weekend of 1/25/25-1/26/25.

Surveyor asked Resident R22 if staff answered call lights in a timely fashion this past weekend of 1/24/25-1/26/25. Resident R22 told Surveyor it depended on the day. Resident R22 stated that sometimes it seems like staff ignore the call lights and that staff have been short here for a long time. Surveyor asked how the resident was aware they short staffed here. Resident R22 told Surveyor that staff always tell Resident R22. Resident R22 informed Surveyor this weekend it was 30 minutes to 2 hours waiting for someone to answer or come into my room. Resident R22 told Surveyor when staff came into my room the staff told Resident R22 they are short staffed. Resident R22 told Surveyor sometimes it was a struggle to get water.

On 1/29/25, at 10:34 AM, Surveyor conducted a phone interview of Family-AAA about a fall by Resident R30 and if family had staffing concerns on 1/26/25.

Surveyor asked Family-AAA about the fall on 1/26/25. Family-AAA informed Surveyor Resident R30 didn't seem like

he was getting the attention Resident R30 needed. Family-AAA told Surveyor when I arrived Resident R30 was wet. Family-AAA informed Surveyor he informed the staff right away that Resident R30 was wet. Family-AAA told Surveyor

he flagged someone down who was walking by and told them Resident R30 was wet. Family-AAA was told by the staff member they would come back. Family-AAA informed Surveyor that Resident R30 was in an uncomfortable position with the head of the bed up and Resident R30 had slid down and was toward the end of the bed. Family-AAA told Surveyor that Family-AAA would have positioned himself, but didn't feel comfortable doing the repositioning.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 29 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Family-AAA told Surveyor that is why Family-AAA asked for someone. Family-AAA told Surveyor he called Family-BBB, because no one had come in yet and Family-AAA was going to leave. Family-AAA informed Level of Harm - Minimal harm or Surveyor someone came in as Family-AAA was getting ready to leave. Family-AAA told Surveyor, he was potential for actual harm not comfortable when he left because Resident R30 seemed very unsteady and confused. Surveyor asked Family-AAA how long it took someone to come in and change Resident R30's wet bed. Family-AAA informed Surveyor Residents Affected - Some it was at least 90 minutes. Surveyor asked if Family-AAA remembered any names of the staff. Family-AAA informed Surveyor he did not remember the names of the staff. Surveyor asked Family-AAA if he was there when Resident R30 fell . Family-AAA told Surveyor that Resident R30 fell after Family-AAA left. Surveyor asked if Family-AAA reported his concerns to staff. Family-AAA informed Surveyor that Family-AAA found a nurse and told the nurse his concern that Resident R30 was unsteady and that no one was around to keep an eye on Resident R30.

On 1/29/25, at 11:12 AM, Surveyor conducted a phone interview with Family-BBB about Resident R30's fall and Family-AAA's staffing concerns and care for Resident R30 on 1/26/25.

Surveyor asked Family-BBB, what the family's recollection of what happened with Resident R30 on 1/26/25. Family-BBB informed Surveyor that Family-AAA called to inform Family-BBB that Resident R30 had been soiled and wet for some time. Family-BBB told Surveyor that after Family-AAA informed Family-BBB that a staff member was informed that Resident R30 needed changing that Family-BBB was concerned about leaving because Resident R30 was unsteady, and it didn't seem to Family-AAA there were staff around to help Resident R30 or keep an eye on Resident R30's unsteady condition. Family-BBB informed Surveyor that Family-BBB made 5 phone calls to the facility with no answer from staff. Family-BBB informed Surveyor a phone call to an off-duty nurse who Family-BBB has the staff member's personal number was made to request help for Resident R30. Family-BBB told Surveyor that

the nurse called the facility, and that nurse was able to get someone into Resident R30's room to provide cares to Resident R30, so Family-AAA could leave. Family-BBB informed Surveyor that Family-AAA said Resident R30 was cleaned up and taken out to the table in the dining area before Family-AAA left. Family-BBB told Surveyor that Family-AAA was given assurances that someone would watch Resident R30 at the table, because Resident R30 was unsteady. Family-BBB told Surveyor that Resident R30 fell sometime after that. Family-BBB informed Surveyor the facility just doesn't have enough people to watch or care for Resident R30 whose has dementia, especially on the weekends.

On 1/29/25, at 01:47 PM, Family-BBB called the Surveyor to provide more information. Surveyor conducted

a phone interview with Family-BBB concerning the staffing and fall concerns that the family has for Resident R30.

Surveyor asked Family-BBB, what Family-BBB wanted to add to the previous information provided to Surveyor. Family-BBB informed Surveyor that Resident R30 will spit his medications out. Family-BBB told Surveyor

she has requested the nurse to stay until Resident R30 swallows the medications. Family-BBB told Surveyor they tell her they will, and Family-BBB will come in and see medications spit out on the floor. Family-BBB told Surveyor there doesn't seem to be enough staff to care for Resident R30 especially the weekends.

On 1/29/25, at 02:41 PM, Surveyor expressed Surveyors concerns to NHA-A, DON-B, Director of Quality (DOQ)-L and Regional Director (RD)-H.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 30 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 Surveyor informed the facility that after interviews with residents, staff and family the Surveyor had concerns with staffing on the weekend of 1/25/25/-1/26/25. Interviews with Scheduler-O and ADON-C, they confirmed Level of Harm - Minimal harm or for the Surveyor the facility did not have the minimum number of staff as indicated by the facilities staffing potential for actual harm communication provided to the Surveyor by Scheduler-O. ADON-C informed the Surveyor, there was a birthday party many staff attended, which made it difficult recruiting for vacant shifts in the schedule. Residents Affected - Some Surveyor informed the facility that family complained that Resident R30 was left wet for at least 90 minutes. During Interviews with other residents and staff, the Surveyor was told the shortage of staff on weekend 1/25/25-1/26/25 impacted call light response times causing significant delays to resident cares.

No additional information was provided at exit as to why the facility did not ensure that the facility had sufficient nursing staff to provide nursing related services to the residents of the first floor.

50700

2.) Resident R23's diagnoses include hemiplegia & hemiparesis following unspecified cerebrovascular disease affecting left non-dominate side, aphasia, dysarthria, dysphasia, facial weakness and gastrotomy.

Resident R23's admission MDS (minimum data set) with an assessment reference date of 11/13/2024, had a BIMS (brief interview mental status) score of 15. A score of 15 indicates that Resident R23 is cognitively intact. Resident R23's functional abilities and goals section, under eating, has a score of 3, which indicated partial to moderate assist is needed with eating.

Resident R23's care plan interventions for alteration in nutrition dated 11/18/2024 documented: Provide, serve diet as ordered, texture upgrade on 1/23/2025, from mechanical soft to regular diet. Under the above-mentioned care plan, it had registered dietitian to evaluate and make diet change recommendations as needed. Resident R23's cerebral vascular accident care plan, under the focus area, it had intervention of: Monitor/document ability to chew and swallow. If resident was presenting with problems, obtain an order for speech therapy to evaluate and treat.

On 1/27/2025, at 9:52 AM, Surveyor interviewed Resident R23 who stated the facility is short staffed a lot. Resident R23 said

this last weekend on 1/25/2025-1/26/2025 was an example of that. Resident R23 stated that Resident R23 sat incontinent for a long period of time. Resident R23 stated that when staff certified nursing assistant (CNA)-III came to answer the call light that CNA-III stated they were very short staffed that weekend.

On 1/27/2025, at 10:40 AM, Surveyor called, Anonymous-DDD related to staffing concerns. Anonymous-DDD, stated there was long wait times. Resident R23 will sit incontinent and for long periods of time. Anonymous-DDD stated that family must call the facility to tell them to answer Resident R23's call light. Anonymous-DDD stated CNAs will leave Resident R23 during feeding Resident R23 to answer other residents call lights. Anonymous-DDD stated Resident R23 was supervision with meals and that staff should not leave Resident R23 during feeding.

Surveyor reviewed Resident R23's care plan and CNA Kardex which revealed that Resident R23 was supervision with meals

during that period of 1/25/2025-1/26/2025.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 31 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0725 On 1/27/2025, at 3:26 PM, Surveyor interviewed Scheduler-O regarding staffing from the weekend of 1/25/2025-1/26/2025. Surveyor explained to Scheduler-O that the number of staff shows less staff during the Level of Harm - Minimal harm or above-mentioned weekend. Surveyor asked Scheduler-O what was done to correct this staffing shortage. potential for actual harm Scheduler-O informed Surveyor they had to work short if staff was not obtained. Scheduler-O wanted to investigate staffing levels and would get back to Surveyor. Residents Affected - Some

On 1/28/2025, at 3:14 PM, Surveyor brought concerns of staffing to the Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Regional Director-H, Assistant Director of Nursing (ADON)-C, Director of Quality Assurance-L and Nurse Consultant-EEE.

No additional information was received related to the staffing concerns mentioned above.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 32 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Ensure each resident must receive and the facility must provide necessary behavioral health care and services. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38829

Residents Affected - Few Based on interview and record review, the Facility did not comprehensively assess to provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 (Resident R22) of 2 Residents reviewed for behavior health services.

*Resident R22 has diagnoses of Vascular Dementia Without Behavioral Disturbance, Major Depressive Disorder, Anxiety Disorder, Attention-Deficit Hyperactivity Disorder, Alcohol Dependence and Opioid Abuse. Resident R22 has had significant behavioral changes and has not received behavioral health services in order for Resident R22 to attain

the highest practicable physical, mental, and psychosocial well-being. The facility did not offer behavioral health services related to diagnoses of both alcohol and drug substance abuse.

Findings include:

The facility's policy and procedure Behavioral Health Services Policy implemented 3/21/21 documents:

Policy Statement:

.It is the policy of the facility to provide Mental Health Services in accordance to State and Federal regulations. The intent of this policy is to ensure that the facility has sufficient staff members who possess

the basic competencies and skills sets to meet the behavioral needs of Residents of whom the facility has assessed and developed care plans

Procedure:

Each Resident will receive and the facility will provide the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with

the comprehensive assessment and plan of care.

1. Behavioral health encompasses a Resident's whole emotional and mental well-being, which includes, but is not limited to, the prevention and treatment of mental and substance use disorders.

2. The facility will have sufficient staff who provide direct services to Residents with the appropriate competencies and skills sets to provide nursing and related services to assure Resident safety and attain or maintain the highest practicable physical, mental and psychosocial well-being of each Resident, as determined by Resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's Resident population.

4. The facility will ensure that, a Resident who displays or is diagnosed with mental disorder or psychosocial difficulty, or who has a history of trauma and/or post-traumatic stress disorder, receives appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 33 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 6. A Resident who displays or is diagnosed with dementia, receives the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being. Level of Harm - Minimal harm or potential for actual harm 10. The facility will provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each Resident. Residents Affected - Few Surveyor also reviewed the facility assessment last reviewed 10/31/24 which documents:

.Facility may accept Residents with, or current Residents may develop, the below common diseases, conditions, physical disabilities, cognitive disabilities, or combinations of conditions that require complex medical care and management.

Psychiatric/Mood Disorders-Psychosis, Impaired Cognition, Mental Disorder, Depression, Bipolar, Disorder, Schizophrenia, Post Traumatic Stress Disorder, Anxiety Disorder, Behavior that Needs Interventions

If it is determined that staff training is required t to care for potential Resident, training will be provided by in house staff or other professionals.

The facility assessment documents there are currently an average of 59 Residents that require behavioral health needs.

1.) Resident R22 was admitted to the facility on [DATE REDACTED] with diagnoses of Hemiplegia and Hemiparesis Following Cerebral Infarction affecting Left Non-Dominant Side, Nontraumatic Subarachnoid and Intracerebral Hemorrhage, Anemia, Chronic Kidney Disease, Stage 3, Insomnia, Vascular Dementia, Unspecified Severity, Without Behavioral Disturbance, Major Depressive Disorder, Anxiety Disorder, Attention-Deficit Hyperactivity Disorder, Alcohol Dependence, and Opiod Abuse.

Resident R22's Quarterly Minimum Data Set(MDS) completed 12/18/24 documents a Brief Interview for Mental Status(BIMS) score to be 15, indicating Resident R22 is cognitively intact for decision making. Resident R22's MDS also documents Patient Health Questionnaire(PHQ-9) score to be 0, indicating no depression, and no behaviors are documented.

Surveyor notes that Resident R22's Preadmission Screen and Resident Review(PASSR) dated 1/24/25, documents Resident R22 does not require specialized services or specialized psychiatric rehabilitative services.

Resident R22's physician orders document Resident R22 is prescribed the following

-Bispirone 10 mg 1 tablet 1 time a day for anxiety

-Depakote 250 mg 1 tablet two times a day for impulse control

-Duloxetine 60 mg capsule one time a day for depression

-Trazodone 50 mg 2 tablets one time a day for insomnia 100 mg

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 34 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 Surveyor reviewed Resident R22's comprehensive care plan which documents the following related to behavioral health needs: Level of Harm - Minimal harm or potential for actual harm -Resident R22 may voice allegations of mistreatment or exploitation by caregivers/family. This behavior appears to be due to continuously wanting in Resident R22's room [ROOM NUMBER]/15/25 Residents Affected - Few -Resident R22 displays socially inappropriate and maladaptive behavior due to attention seeking. Symptoms and problems are manifested by: Making inappropriate phone calls to the emergency medical system when an actual emergent/crisis situation does not exist 1/15/25

-Resident R22 has a behavior problem due to sexually inappropriate behavior, touching toward female staff/does not show this behavior towards other Residents. Wrote staff names on Resident R22 faces, cups, and bed side table with marker. Resident R22 masturbates in front of female staff. Resident R22 will put on call light and if it is not the aide Resident R22 wants, Resident R22 will say Resident R22 does not want anything or will request the specific aide to come. Resident R22 will then say no one answered call light. Resident R22 calls police. 9/27/23, Revised 1/9/25

-Resident R22 has a mood problem 9/20/23

Resident R22's Visual Bedside Kardex Report developed for CNAs effective 1/27/25 does not document specific interventions for staff when Resident R22 is sexually inappropriate, or displaying mood concerns.

On 1/2/25, Resident R22 signed a Special Behavior Contract. On 1/8/25, Resident R22 was issued a 30 day discharge notice due to Resident R22 not abiding by the provisions in the contract.

Surveyor reviewed Resident R22's electronic medical record(EMR). Surveyor reviewed progress notes of Resident R22 going back to 8/1/24. Surveyor notes there are no behaviors documented of Resident R22 until 11/30/24.

11/30/24 it is documented that Resident R22 was continuously turning on light for CNA to come in room and sexually harass CNA. Surveyor reviewed all progress notes. Surveyor noted that Resident R22's behaviors have escalated since 11/30/24.

Surveyor noted that the facility did not review Resident R22's behavior as an Interdisciplinary Team(IDT) for a root/cause analysis of why Resident R22's behavior escalated.

Surveyor notes that Resident R22 has been evaluated and treated by the psychologist and psychiatrist.

On 1/21/25, Psych-LPC-WWW documented a visit with Resident R22.

There is no documentation that the facility communicated with Psych-LPC-WWW that Resident R22 on 1/17/25 was observed to be banging Resident R22' s head on the headboard and voiced Resident R22 would throw self out of the bed.

On 1/23/25, Psych-XXX evaluated and treated Resident R22. There is no documentation that the facility communicated with Psych-XXX that Resident R22 on 1/17/25 was observed to be banging Resident R22' s head on the headboard and voiced Resident R22 would throw self out of the bed.

On 1/28/25, at 1:11 PM, Surveyor interviewed Director of Social Services (DOSS)-JJJ. DOSS-JJJ was not able to provide additional information in regards to Resident R22's behavioral health services.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 35 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0740 On 1/29/25, at 11:19 AM, does not recall being informed that on 1/17/25, Resident R22 was observed banging head

on headboard. DOSS-JJJ stated that so much goes on, I don't remember anything. If an incident report was Level of Harm - Minimal harm or implemented due to Resident R22 banging head on headboard, it would have been reviewed by the IDT. potential for actual harm

On 1/29/25, at 6:22 AM, Surveyor reviewed Resident R22's comprehensive care plan and notes that Resident R22's care plan Residents Affected - Few has not been updated with Resident R22's behavior of banging head on headboard and stating Resident R22 wanted to throw Resident R22 out of bed because Resident R22 did not want to leave facility.

On 1/28/25, at 3:32 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Nurse Consultant (NC)-EEE, Regional Director (RD)-H, and Director of Quality Assurance (DOQA)-L that DOSS-JJJ was unaware of the new behavior of Resident R22 banging head on headboard. Surveyor asked what the facility's expectation is for staff to complete an incident report. DON-B listed examples. Surveyor asked if a Resident was demonstrating behavior reflective of self harm, like banging head on headboard, would an incident report be expected to be completed. DON-B confirmed that an incident report would be expected to be completed. Surveyor expressed concern that Resident R22 has significant behavioral health diagnoses and behaviors with an increase of sexual inappropriateness since 11/30/24, and the IDT did not root/cause analysis in order to develop non-pharmalogical interventions.

On 1/29/25, at 9:54 AM, Surveyor interviewed Licensed Practical Nurse (LPN)- I via telephone who wrote the progress note documenting Resident R22 was observed banging head on headboard and stating I am trying to throw myself out of bed to get out of here. LPN-I informed Surveyor that Resident R22 banging head on headboard lasted about 5 minutes and perceived it as a temper tantrum. LPN-I stated that LPN-I did not observed any injuries and Resident R22 denied pain. LPN-I did not complete assessments with the incident and does not remember informing any supervisors of the incident.

Surveyor noted that at 5:35 PM, on 1/28/25, LPN-I wrote a clarification note in Resident R22's progress notes stating that Resident R22 was upset and bumping head on headboard not with force and not hard enough to sustain injury, just enough to rattle bed while Resident R22 was yelling threats to call 911 or to put self on floor. LPN-I documented behavior reflected a temper tantrum not as though Resident R22 intended to harm self. Resident R22's behavior was attention seeking not harmful.

On 1/29/25, at 2:41 PM, Surveyor again informed Director of Quality Assurance (DOQA) of the concern that behavioral health services were not provided to Resident R22 as the IDT has not reviewed a root/cause as to why Resident R22's behavior has escalated since 11/30/24, and facility staff document Resident R22's behaviors with no person-centered interventions developed and implemented for Resident R22.

DOQA- L stated that Resident R22 was going to be followed up by neurology and that the appointment has been moved up due to Resident R22's behavior. However, Surveyor reviewed the additional information provided by the facility and there is not date of when the facility called to move up the neurology appointment or when the neurology appointment is scheduled for.

No additional information was provided as to why the facility did not provide Resident R22 with the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 36 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38829

Residents Affected - Few Based on interview and record review, the facility did not provide pharmaceutical services to meet the needs of for 1(Resident R26) of 2 Residents reviewed.

* Resident R26 was discharged on [DATE REDACTED] from the facility and was sent home with discontinued medications of Abilify, Prozac, and Zoloft. The facility did not follow procedure of removing the medications from the medication cart and returning the discontinued medication to the pharmacy.

* Resident R26 did not receive scheduled medications one hour before or one hour after the scheduled time 22 times between 11/1/24 and 11/26/24.

Findings include:

The facility's policy Disposal of Medications and Medication-Related Supplies last revised January 2018 documents:

Policy

.When medications are discontinued by the prescriber or the Resident is discharged and medications are not sent with the Resident, the medications are marked as discontinued and stored in a secure and separate area from the active supply, marked discontinued and securely stored until destroyed.

Procedures

A. If a prescriber discontinues a medication and, in the nurse's judgment, it is unlikely to be recorded within 7 days, the medication container is marked with a stop drug or discontinued sticker, and the date of discontinuation is indicated along with the name of the nurse.

B. The nurse documents the order to discontinue the medication in the Resident's record. The Physician's Order sheet and the Medication Administration Record(MAR) are updated by highlighting the order in yellow, striking through the order and writing D/C across or next to the discontinued order. Also, the discontinued date should also be recorded.

C. Medications are removed from the medication cart or active supply immediately upon receipt of an order to discontinue(to avoid inadvertent administration). Medications awaiting disposal or return are stored in a locked secure area designated for that purpose until destroyed or picked up by pharmacy.

F. Notify the pharmacy that the medication has been discontinued so that the Resident's profile can be updated and prevent any cycle fill dispensing that is in place.

Returning Medications to Pharmacy

Policy

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 37 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 .With the exception of controlled substances or where prohibited by state law, discontinued or unused medications are returned to the provider pharmacy for credit whenever possible. Level of Harm - Minimal harm or potential for actual harm Procedures

Residents Affected - Few A. Medications other than controlled medications or where prohibited by state law may be returned to the provider pharmacy if the medication is in a sealed package or container.

B. For each medication returned, an entry is made on the medication disposition form. The entry includes the date, medication name and strength, quantity, and prescription number.

C. Medications to be returned to the pharmacy should be secured until the time of pick up.

D. The medication disposition form is kept with the medications for return until picked up by pharmacy. The receiving pharmacy representative signs the form to indicate receipt and give the original to the Director of Nursing. Once copy is kept by the pharmacy.

E. Completed medication disposition forms are kept by the facility for 2 years.

1.) Resident R26 was admitted to the facility on [DATE REDACTED] with diagnoses of Hypertensive Heart and Chronic Kidney Disease with Heart Failure and with Stage 5 Chronic kidney Disease, Type 2 Diabetes Mellitus, Peripheral Vascular Disease, End Stage Renal Disease, Mild Protein-Calorie Malnutrition, Chronic Obstructive Pulmonary Disease, Acquired Absence of Left Leg Below Knee, Adjustment Disorder with Mixed Disturbance of Emotions and Conduct, Vascular Dementia, Major Depressive Disorder, and Anxiety Disorder. Resident R26 had an activated Health Care Power of Attorney (HCPOA) during Resident R26's stay at the facility. Resident R26 discharged from the facility on 11/26/24.

Resident R26's Quarterly Minimum Data Set(MDS) completed on 9/5/24 documented Resident R26 had a Brief Interview for Mental Status(BIMS) score of 15, indicating Resident R26 was cognitively intact. Resident R26 had range of motion impairment

on one side of lower extremity. Resident R26's MDS also documented Resident R26 was independent with eating. Resident R26's MDS documented Resident R26 required substantial/maximum assistance, set-up for upper and lower dressing, substantial/maximum assistance for mobility and dependent for transfers.

On 1/28/25, at 12:01 PM, Surveyor interviewed HCPOA-PPP via telephone. HCPOA-PPP informed Surveyor that the facility sent 3 bubble packs of medications home with Resident R26 on 11/26/24, the day of discharge from

the facility. HCPOA-PPP informed Surveyor of the following medications sent home with Resident R26.

Abilify-date issued on bubble pack 10/21/24, 12 missing

Zoloft-date issued on bubble pack 8/25/24, 7 missing

Prozac-date issued on bubble pack 10/21/24, 8 missing

Surveyor reviewed the list of medications signed by Resident R26's physician on 11/21/24 sent to pharmacy of Resident R26's choice to be filled for discharge on 11/26/24. Abilify, Zoloft, and Prozac are not documented on the list of medications being ordered for discharge.

Surveyor reviewed Resident R26's psychiatric progress notes.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 38 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 On 9/11/24, APNP-QQQ changed the Zoloft 50 mg to Prozac 20 mg. APNP-QQQ documented that Resident R26 had

a history of refusing of medications. Level of Harm - Minimal harm or potential for actual harm On 11/6/24, Psych-RRR documented that Resident R26 was refusing the Abilify and Prozac on a consistent basis. Psych-RRR discussed with HCPOA and discontinued the medications. Residents Affected - Few Zoloft-discontinued 9/11/24

Prozac and Abilify-discontinued 11/6/24

On 1/28/25, at 11:20 AM, Surveyor interviewed Unit Manager (UM)-FF who confirmed UM-FF was familiar with Resident R26. UM-FF confirmed that any discontinued medications should be sent back to the pharmacy.

On 1/28/25, at 11:52 AM, UM-FF confirmed that Resident R26 should not have been discharged from the facility with discontinued medications.

The facility's policy Medication Administration-General Guidelines last revised December 2019 documents:

Policy

Medications are administered as prescribed in accordance with good nursing principles and practices and only by persons legally authorized to do so. Personnel authorized to administer medications do so after they have been properly oriented to the facility's medication distribution system. The facility has sufficient staff and a medication distribution system to ensure safe administration of medications without unnecessary interruptions.

Procedures

B. Administration

12. Medications are administered with 60 minutes of scheduled time.

D. Documentation(including electronic)

1. The individual who administers the medication dose records the administration on the Resident's Medication Administration Record(MAR) directly after the medication is given. At the end of each medication pass, the person administering the medications reviews the MAR to ensure necessary doses were administered and documented.

6. If a dose of regularly scheduled medication is withheld, refused, not available, or given at a time other than

the scheduled time, the space provided on the front of the MAR for that dosage administration is initialed and circled.

Surveyor reviewed Resident R26's physician orders for the month of November 2024. All of Resident R26's medications were to be administered one time a day.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 39 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 Surveyor reviewed Resident R26's Medication Administration Audit Report provided to Surveyor on 1/29/25, at 10:25 AM. The Medication Administration Audit Report details the scheduled time to be administered and the Level of Harm - Minimal harm or actual administration time. Surveyor reviewed the audit times from 11/1/24-11/26/24 for Resident R26's administered potential for actual harm medications. Surveyor noted the administration time for Resident R26's medications to be administered was scheduled for 6:30 AM. Residents Affected - Few For 22 days in November, the audit report documents that Resident R26 received medications late past the 60 minutes per facility policy. The following was documented for Resident R26's administration of medications:

11/1/24-administered at 12:28 PM

11/4/24-administered at 9:43 AM

11/6/24-administered at 9:18 AM

11/7/24-administered at 9:56 AM

11/8/24-administered at 9:56 AM

11/9/24-administered at 1:51 PM

11/10/24-administered at 12:27 PM

11/11/24-administered at 9:11 AM

11/12/24-administered at 9:59 AM

11/13/24-administered at 11:13 AM

11/14/24-administered at 11:10 AM

11/15/24-administered at 11:30 AM

11/16/24-administered at 12:26 PM

11/17/24-administered at 10:01 AM

11/19/24-administered at 8:09 AM

11/20/24-administered at 9:18 AM

11/21/24-administered at 8:25 AM

11/22/24-administered at 9:50 AM

11/23/24-administered at 12:56 PM

11/24/24-administered at 12:01 PM

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 40 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0755 11/25/24-administered at 10:18 AM

Level of Harm - Minimal harm or 11/26/24-administered at 10:34 AM potential for actual harm Resident R26 attended dialysis on day shift 3 times a week while at the facility Residents Affected - Few Surveyor did not note any documentation in Resident R26's medical record regarding Resident R26's medication being administered late.

On 1/29/25 at 11:13 AM, Surveyor asked Licensed Practical Nurse (LPN)-F when medication is scheduled at

a certain time when can this medication be administered. LPN-F informed Surveyor a medication could be administered minimum of 2 hours after the scheduled time. LPN-F stated that if LPN-F would give a medication late, prior to administrating, LPN-F would confirm with the physician it was okay to administer the medication. Surveyor interviewed LPN-LLL who stated the medication should be administered within 30 minutes after the scheduled time.

On 1/29/25, at 12:15 PM, Surveyor interviewed LPN-NNN in regards to procedure for administrating medications. LPN-NNN stated that if a medication was to administered at 6:30 AM, LPN-NNN stated that LPN-NNN could administer medications no later than 10:00 AM. LPN-NNN stated LPN-NNN would inform

the Director of Nursing and the physician.

On 1/29/25, at 2:41 PM, Surveyor informed Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Nurse Consultant (NC)-EEE, Regional Director (RD)-H, and Director of Quality Assurance (DOQA)-L that Resident R26 received Resident R26's medications late on 22 days. Surveyor also shared that procedures of removing discontinued medications and sending to pharmacy or destroying medications was not followed as Resident R26 was discharged home on 11/26/24 with discontinued medications.

No additional information was provided to Surveyor as to why Resident R26's medication was administered late and discontinued medications were sent home with Resident R26 on day of discharge.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 41 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 38829

Residents Affected - Few Based on observation, interview and record review, the facility did not provide 1 (Resident R27) of 4 Residents reviewed for dietary services, with food accommodations and preferences as listed on the Resident's meal tickets.

*Resident R27 did not receive preferred items per meal ticket for breakfast on 1/29/25.

Findings Include:

The facility's undated policy and procedure Accuracy and Quality of Tray Line Service documents:

Policy:

Tray line positions and set up procedures will be planned for efficient and orderly delivery. All meals will be checked for accuracy by the fool and nutrition services staff, and by the service staff prior to serving the meal to the individual.

Procedure:

4. The meal will be checked against the therapeutic diet spread sheet to assure that foods are served as listed on the menu.

5. Staff will refer to the medal identification card/ticket for food dislikes, allergies and other details and substitute approximately for those items.

6. Each meal will be checked for:

a. Correct name, room number, and diet order

b. Accuracy of following the therapeutic diet extension

c. Proper portion sizes

d. Food and beverage preferences, allergies, intolerances and/or special food requests

e. Neatness of tray and attractiveness of the food served

7. Problems with meal accuracy should be resolved immediately

8. Ongoing problems should be brought to the attention of the director of food and nutrition services

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 42 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0806 1.) Resident R27 was admitted to the facility on [DATE REDACTED] with diagnoses of Type 2 Diabetes Mellitus, Paroxysmal Atrial Fibrillation, Morbid Obesity, End Stage Renal Disease, Adult Failure to Thrive, Dependence on Renal Level of Harm - Minimal harm or Dialysis, Major Depressive Disorder, and Generalized Anxiety Disorder. potential for actual harm Resident R27's Admission Minimum Data Set(MDS) completed 12/13/24 documents a Brief Interview for Mental Residents Affected - Few Status(BIMS) score to be 15, indicating Resident R27 is cognitively intact for daily decision making. Resident R27's MDS also documents that Resident R27 requires set-up for eating, dependent for transfers and sit to lying mobility, supervision for upper body dressing and substantial/maximum assistance for lower body dressing. Resident R27 has range of motion impairment on one side of lower extremity.

Resident R27 receives dialysis 3 times a day.

On 3/28/25, at 3:13 PM, Surveyor interviewed Resident R27. Resident R27 informed Surveyor that Resident R27 has not been getting items on Resident R27's trays per preferences. Resident R27 stated that Resident R27 has not been getting Nepro as ordered by physician. Resident R27 stated that Resident R27 frequently does receive meal preferences and has to order out for food as a result.

Surveyor reviewed Resident R27's current physician orders and notes Resident R27 has Nepro with meals, 3 times a day to aid

in weight stability, wound healing, and overall healing effective 1/21/25.

On 1/29/25, at 8:35 AM, Surveyor observed Resident R27's breakfast tray. Resident R27 had cold cereal, pears, juice, toast, and milk. Per Resident R27's breakfast meal ticket, additionally Resident R27 should have received a banana, coffee, hot cereal, 8 oz (ounces) water, and Nepro. Resident R27 stated that Resident R27 loves bananas on a daily basis and would eat

the hot cereal if it would have been on the tray.

On 1/29/25, at 9:10 AM, Surveyor had Dietary Manager (DM)-MMM and Registered Dietitian (RD)-KKK observe along with Surveyor Resident R27's breakfast tray. DM-MMM and RD-KKK agreed that Resident R27 did not receive items listed on Resident R27's breakfast meal ticket. DM-MMM explained that the Certified Nursing Assistants(CNAs) are responsible for placing the liquids on the trays. DM-MMM stated the CNAs are not reading the meal tickets and placing the required items on the tray per Resident ticket. DM-MMM had Surveyor observe the location where Resident trays are assembled by the CNAs and the Dietary Aide. DM-MMM should be informing the Dietary Aide that Resident R27 needs Nepro on the tray. DM-MMM stated the Dietary Aide would go to

the refrigerator and take out a Nepro and give to the CNA to place on Resident R27's tray. DM-MMM stated that it is

the responsibility of both the CNA and Dietary Aide to make sure the Resident receives everything listed on

the meal ticket. DM-MMM stated there is an issue with Residents not receiving items on their trays based on their meal tickets. DM-MMM agreed that there is a problem with CNAs and Dietary Aides not reading tickets and placing appropriate items on Resident trays.

On 1/29/25, at 2:41 PM, Surveyor shared the concern with Nursing Home Administrator (NHA)-A, Director of Nursing (DON)-B, Nurse Consultant (NC)-EEE, Regional Director (RD)-H, and Director of Quality Assurance (DOQA)-L that Resident R27's meal ticket items, was not what Resident R27 received on the breakfast tray, especially Nepro which is essential for Resident R27's renal diet and healing.

No additional information was provided by the facility at this time.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 43 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 Provide and implement an infection prevention and control program.

Level of Harm - Minimal harm or **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 20483 potential for actual harm Based on observation, interview, and record review the facility did not maintain an infection prevention and Residents Affected - Few control program designed to reduce the transmission of disease and infection for 3 (Resident R25, Resident R24, & Resident R33) of 5 Residents.

* Appropriate hand hygiene was not observed during incontinence cares for Resident R25.

* Appropriate hand hygiene was not observed during a wound treatment observation for Resident R24.

* NHA (Nursing Home Administrator)-A entered Resident R33's room to answer Resident R33's call light without placing on PPE (Personal Protective Equipment). Resident R33 was on isolation for COVID.

Findings include:

The facility's policy titled, Infection Control - Hand Hygiene and dated 2/4/21 under Policy Statement documents The facility's policy is to perform hand hygiene per national standards from the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO). Under Policy Guidelines documents 1. Soap and water are required for hand hygiene when: a. Hands are visibly soiled or contaminated with blood or other body fluids; b. After caring for residents with a diarrheal infection such as C. (Clostridium) difficile; c. After potential exposure to body fluid; d. Before and after eating or handling food; and e. After personal use of toilet. 2. Alcohol-based hand sanitizer is appropriate for decontaminating the hands: a. Before direct resident contact; b. Before putting on gloves; c. Before inserting an invasive device; d. After contact with a resident; e. When moving from a contaminated body site to a clean body site during resident care; f. After contact with body fluids, excretion, mucous membranes, non-intact skin, or wound dressing (if hands aren't visibly soiled); g. After removing gloves; h. After contact with inanimate objects in

the resident's environment.

1.) Resident R25's diagnoses includes hemiplegia and hemiparesis following cerebral infarction affecting left non dominate side, hypertension, morbid obesity, chronic kidney disease, anxiety disorder, and depression.

Resident R25's quarterly MDS (minimum data set) with an assessment reference date of 11/14/24 has a BIMS (brief

interview mental status) score of 15 which indicates that Resident R25 is cognitively intact. Resident R25 is assessed as not having any behavior including refusal of cares. Resident R25 is assessed as being dependent for toileting hygiene & toilet transfer, and substantial/maximal assistance for rolling left and right. Resident R25 is assessed as being occasionally incontinent of urine and frequently incontinent of bowel.

On 1/27/25, at 10:21 a.m. CNA (Certified Nursing Assistant)-VVV entered Resident R25's room. Surveyor asked CNA-VVV what she was going to do. CNA-VVV replied wash Resident R25 up. CNA-VVV then explained she's waiting for the other staff to assist. CNA-VVV informed Surveyor she was going to make sure they know I'm ready and left Resident R25's room while wearing gloves on both hands.

At 10:26 a.m., CNA-VVV returned to Resident R25's room stating two CNAs are coming to help.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 44 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 At 10:27 a.m. Scheduler-O entered Resident R25's room, washed her hands, and placed gloves on. CNA-VVV removed Resident R25's blue comforter, and Scheduler-O placed a wash basin on Resident R25's over bed table. Level of Harm - Minimal harm or potential for actual harm At 10:31 a.m. CNA-Y entered Resident R25's room washed her hands and placed gloves on. Scheduler-O placed a sheet over Resident R25's gown, asked Resident R25 if she wanted to wash her own face & handed Resident R25 a wash cloth. The Residents Affected - Few head of Resident R25's bed was lowered and Scheduler-O informed Resident R25 she was going to wash her upper body. Resident R25's gown was removed, Scheduler-O washed Resident R25's right upper body while CNA-VVV started to wash Resident R25's left upper body. Scheduler-O asked Resident R25 if she was in pain. Resident R25 replied yes. Scheduler-O asked Resident R25 if

she received her pills. Resident R25 replied no, I didn't see the nurse this morning. Scheduler-O informed CNA-VVV & CNA-Y to stop. Scheduler-O removed her gloves, washed her hands, and left Resident R25's room.

At 10:43 a.m. Scheduler-O returned to Resident R25's room, washed her hands, placed gloves on and stated she's coming.

At 10:45 a.m. LPN (Licensed Practical Nurse)-II entered Resident R25's room and administered medication to Resident R25.

At 10:46 a.m. Scheduler-O and CNA-VVV finished washing Resident R25's upper body. Scheduler-O stated to Resident R25 going to cross your leg then stated let me do your front first. Scheduler-O washed under Resident R25's abdominal fold, CNA-VVV & CNA-Y opened Resident R25's legs and Scheduler-O washed Resident R25's frontal perineal area. Resident R25's right leg was crossed over to the left and staff positioned Resident R25 on the left side. Surveyor observed the sheet under Resident R25 had a large yellowish brown urine stain and the incontinence product contained urine. Surveyor asked Scheduler-O if that's a urine stain on the sheet. Scheduler-O replied yes. Scheduler-O washed Resident R25's back and buttocks. Scheduler-O removed a pair of gloves from her hands. Surveyor observed Scheduler-O had been wearing two pairs of gloves. Scheduler-O placed a sheet on the bed and had Resident R25 roll onto her back. CNA-VVV, Scheduler-O & CNA-Y positioned Resident R25 on the right side, CNA-Y washed Resident R25's buttocks and

the incontinence product was removed. CNA-Y did not remove her gloves and perform hand hygiene. CNA-Y placed a fitted sheet on the left side of the mattress along with a bath blanket for a draw sheet and an incontinence product was placed under Resident R25. Resident R25 rolled on to her back, a gown and deodorant was placed

on Resident R25. CNA-VVV, Scheduler-O & CNA-Y positioned Resident R25 on the left side and the fitted sheet was placed on

the right side of the bed. Resident R25 rolled onto her back. Resident R25 stated I feel and smell better. Resident R25 was covered with

a sheet and a white blanket. Resident R25 asked are you going to put those on my feet referring to the pressure relieving boots. Scheduler-O replied let me take my gloves off and wash my hands. Scheduler-O removed her gloves, washed her hands and placed the pressure relieving boots on Resident R25. CNA-Y removed her gloves and washed her hands. CNA-VVV removed her gloves and left Resident R25's room with two bags with soiled items. CNA-VVV did not perform hand hygiene prior to leaving Resident R25's room.

On 1/28/25, at 11:25 a.m., Surveyor met with LPN (Licensed Practical Nurse)-II who is the facility's infection preventionist. Surveyor asked LPN-II when she would expect staff to perform hand hygiene. LPN-II informed Surveyor they should wash their hands upon entering room, after cleaning a brief, anytime their hands have touched something soiled and before leaving the room. Surveyor asked how many pairs of gloves should staff wear. LPN-II replied one pair at a time. Surveyor asked after performing incontinence cares should staff remove their gloves and perform hand hygiene. LPN-II replied yes I tell them they can't wash their hands enough. Surveyor informed LPN-II of the observations during personal cares Scheduler-O wearing two pairs of gloves and not appropriate hand hygiene during this observation.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 45 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 1/28/25, at 3:32 p.m., NHA (Nursing Home Administrator)-A was informed of the above. No additional information was provided. Level of Harm - Minimal harm or potential for actual harm 2.) Resident R24 is on enhanced barrier precautions for wounds.

Residents Affected - Few On 1/28/25, at 9:05 a.m., Surveyor observed UM (Unit Manager)-F, who is the facility's wound nurse, place a gown & gloves on and enter Resident R24's room with Resident R24's treatment supplies which were placed on Resident R24's bed. UM-F removed the kerlix gauze & dressing from Resident R24's left heel and the left amputation site. UM-F removed gauze, dressing on Resident R24's right heel & toes, and the gauze in between Resident R24's right toes. UM-F then removed

the dressing from the back of Resident R24's left lower leg. Surveyor observed all the soiled items were placed directly

on the device between the mattress & foot board. UM-F removed her gloves & gown and stated she was going to get a garbage bag. Surveyor did not observe UM-F perform any hand hygiene prior to leaving Resident R24's room.

At 9:10 a.m. UM-F entered Resident R24's room wearing a gown & gloves and brought in Resident R24's breakfast tray sitting

the tray on the over bed table. UM-F placed the soiled dressings in the clear plastic bag, moved the garbage can closer with her gloved hand, removed her gloves and placed new gloves on. UM-F did not perform any hand hygiene. UM-F stated she was going to clean the left leg with normal saline. After cleansing with normal saline, UM-F applied medihoney with a cotton applicator on the wound bed, placed calcium alginate over the medihoney and covered the wound with a foam dressing. UM-F stated lets move on to these feet. UM-F applied betadine to the left foot where Resident R24's toes had been amputated, lifted Resident R24's left leg up and applied betadine to the left heel. Resident R24 was able to hold her leg up while UM-F opened the ABD (abdominal) pads. UM-F placed an ABD pad on the left heel & amputation site and wrapped Resident R24's left foot with Kerlix.

At 9:17 a.m. UM-F stated one more foot. UM-F applied Betadine to Resident R24's right toes with the exception of the toes that had been amputated. UM-F then applied Betadine to the right heel. UM-F informed Surveyor she's going to take a piece of gauze what they like to call toe floss and weaved the gauze in between Resident R24's right toes. UM-F placed an ABD pad on the right heel, right toes and wrapped the right foot with Kerlix gauze. UM-F informed Resident R24 she was good to go, moved the over bed table closer to Resident R24, removed her gown & gloves and washed her hands.

On 1/28/25, at 11:30 a.m. Surveyor asked LPN (Licensed Practical Nurse)-II, who is the facility's infection preventionist when staff should perform hand hygiene during treatment. LPN-II informed Surveyor when get

in the room after remove the dressing, after removing gloves, and before leaving the room. Surveyor asked LPN-II if should perform hand hygiene after completing one site if there are multiple areas. LPN-II informed Surveyor one site should be done at a time in case one of the wounds are infected. Surveyor asked after cleansing the wound bed should the nurse remove their gloves and perform hand hygiene prior to completing

the treatment. LPN-II informed Surveyor she would have to ask UM-F. Surveyor informed LPN-II Surveyor's concern regarding hand hygiene is with UM-F.

On 1/28/25, at 12:49 p.m., Nurse Consultant-EEE informed Surveyor they are doing education for UM-F and LPN-II and after the education they will have to do a competency to ensure what they are educated on is being done.

On 1/28/25, at 3:32 p.m., NHA (Nursing Home Administrator)-A was informed of the above. No additional information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 46 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 38829

Level of Harm - Minimal harm or The facility's policy Infection and Control Guidance for COVID-19 last revised 10/25/24 documents: potential for actual harm 2) Adherence to the core principles of COVID-19 infection and prevention to mitigate risk associated with Residents Affected - Few potential exposure as follows:

-Facility will provide instructional guidance to all who enter the facility for signs and symptoms of COVID-19

-Proper hand hygiene is performed

-Staff will wear a well-fitting facemask that fully covers the mouth and nose, in accordance with CDC guidelines

-Instructional signage throughout the facility(hand hygiene, face coverings, social distancing, signs and symptoms of COVID-19, infection control precautions)

-Appropriate use of Personal Protective Equipment(PPE)

I Implement Source Control Measures

5. Eye protection(goggles or a face shield that covers the front and sides of the face) worn during all patient care encounters

II. Universal Use of Protective Equipment for Health Care Providers(HCP)

1. HCP should always use PPE as described below:

-NIOSH-approved N95 or higher level respirators should be used for all aerosol-generating procedures or procedures that may cause uncontrolled respiratory secretions. -Eye protection

3. Reference CDS Strategies for Optimizing the Supply of Facemasks and Optimizing Personal Protective Equipment Supplies

3.) Resident R33 was admitted to the facility on [DATE REDACTED] with diagnoses of Pneuomocystosis, Immunodeficiency, Chronic Obstructive Pulmonary Disease, Lung Transplant Status, Other Asthma, Dysthymic Disorder, Chronic Kidney Disease, and COVID-19.

Resident R33's Quarterly Minimum Data Set(MDS) completed 12/3/24 documents Resident R33's Brief Interview for Mental Status(BIMS) score to be 8, indicating Resident R33 demonstrates moderately impaired skills for decision making. Resident R33's MDS also documents Resident R33 required set-up for eating, partial/moderate assistance for mobility, and substantial/maximum assistance for transfers.

Resident R33's electronic medical record(EMR) documents that Resident R33 went to a transplant appointment on 1/17/25 and was transferred to the hospital due to being COVID-19 positive. Resident R33 was readmitted to the facility on [DATE REDACTED] and placed in isolation until removal from isolation on 1/28/25.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 47 of 48 525424 Department of Health & Human Services Printed: 09/10/2025 Form Approved OMB Centers for Medicare & Medicaid Services No. 0938-0391

STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A. Building 525424 B. Wing 01/29/2025

NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE

Aria of Brookfield 18740 W Bluemound Rd Brookfield, WI 53045

For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency.

(X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0880 On 1/27/25, at 9:58 AM, Surveyor observed Resident R33's call light on and door open. Surveyor observed a cart outside Resident R33's room and a sign posted on the door of Resident R33's room. Surveyor observed Nursing Home Level of Harm - Minimal harm or Administrator (NHA)-A go into Resident R33's room. Surveyor notes that NHA-A did not don a gown, mask, gloves, or potential for actual harm eye protection. Surveyor observed NHA-A touch Resident R33's overbed table which was next to Resident R33's bed. NHA-A came out of the room and did not put hand sanitizer on or wash NHA-A's hands. NHA-A went down the Residents Affected - Few hallway.

On 1/27/25, at 12:43 PM, Surveyor observed the cart outside of Resident R33's room. Resident R33's door was half open. On top of the cart was a box of gloves, and bottle of hand sanitizer on top of the cart. Surveyor counted approximately 9 gowns , approximately 15 eye shields, approximately half box of surgical masks, box of N-95 masks.

The mask outside Resident R33's room reads:

Special Droplet/Contact Precautions

In addition to Standard Precautions Only essential personnel should enter this room.

Everyone Must: including visitors, doctors, and staff:

Clean hands when entering and leaving the room

Wear mask(fit tested N-95 or higher required when performing aerosol-generating procedures)

Wear eye protection(faceshield or goggles)

Gown and glove at the door

Keep Door Closed

On 1/27/25, at 1:38 PM, Surveyor interviewed Infection Control Preventionist (ICP)-II. ICP-II confirmed that anyone entering Resident R33's room should wear a mask, preferably a N-95, gown, gloves and eye protection. ICP-II confirmed that anyone entering Resident R33's room should wash hands prior to and upon leaving Resident R33's room. ICP-II informed Surveyor that Resident R33 will be out of isolation on 1/28/25. ICP-II stated that ICP-II is learning infection control on the job.

On 1/27/25, at 3:11 PM, Surveyor discussed with NHA-A the above observations. Surveyor shared the concern that COVID-19 precautions were not followed by NHA-A with NHA-A, Director of Nursing (DON)-B, Regional Director (RD)-H, and Nurse Consultant (NC)-EEE. NC-EEE stated that NC-EEE will do training immediately.

No additional information was provided.

FORM CMS-2567 (02/99) Event ID: Facility ID: If continuation sheet Previous Versions Obsolete Page 48 of 48 525424