Brewer Center for Health & Rehabilitation, LLC

Inspectors wroteBased on review of a reportable incident form, record review, and interviews the facility failed to ensure that a resident was free from injury when the facility staff failed to properly transfer a resident causing the resident to sustain a fractured rib for 1 of 1 residents reviewed for falls [Resident #1 (R1)].

Inspectors wroteBased on clinical record reviews and interviews, the facility failed to ensure physician orders were followed for 4 of 6 resident's reviewed for medications (Resident #45 [R45], R103, R125, and R74).

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety by not storing dishes and food in a sanitary manner. In addition, the facility failed to ensure that plumbing fixtures were properly installed to prevent backflow as required by the Maine State Plumbing Code for 2 of 4 days of survey (4/27/26 and 4/29/26).

Inspectors wroteBased on observation and interview the facility failed to promote care to residents in a manner that maintains each resident's dignity for 1 of 2 units observed for dining services (Unit A).

Inspectors wroteBased on interviews and clinical record review, the facility failed to ensure a baseline care plan was developed and implemented within 48 hours of admission that included the instructions needed to provide the minimum healthcare information necessary to properly care for 1 of 5 sampled residents (Resident #122 [R122]).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure bed mattresses were compatible with bed frames and identify areas of possible entrapment for 3 of 102 residents observed on survey [Resident #78 (R78, R47, and R45].

Inspectors wroteBased on record review, facility investigation and interview, the facility failed to ensure that a resident's care plan was followed for transfer assist for 1 of 1 sampled resident (Resident #1 [R1]). On 2/19/26, R1's clinical record was reviewed. Documentation indicate that in the past year, R1 suffered a stroke and his/her left side is affected. R1's left arm is flaccid and R1 is unable to move the left arm. Documentation in a nurse note, dated 2/10/26, indicated CNA1 was transferring R1 from his/her wheelchair to the bed. The transfer failed and CNA1 lowered R1 to the floor. The charge nurse assessed the resident and no visible injuries were identified. A review of R1's care plan for the problem deficit in functional mobility, dated 7/28/25, indicated two staff are needed for transfers. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 5 of 8 residents reviewed on survey (Resident #14 [R14], [R40] [R29], [R32], and [R82]).

Inspectors wroteBased on clinical record reviews and interview, the facility failed to ensure the attending physician made required visits, at least every 60 days for 6 of 8 sampled residents (Resident #1 [R1], [R25], [R37], [R40], [R8], and [R3]).

Inspectors wroteBased on performance evaluation reviews and interview, the facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1], CNA2, CNA3, CNA4).

Inspectors wroteBased on record review and interview, the facility failed to respect a resident's choice for the use of an incontinent product preference for 1 of 1 sampled resident (Resident #11 [R11]) who's incontinent product choice was denied.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to formulate an advanced directive, and/or ensure a resident's right to formulate an advanced directive regarding code status (cardiopulmonary resuscitation [CPR]) was accurate in the electronic record for 2 of 10 residents (Residents #98 [R98] and [R8]).

Inspectors wroteBased on record reviews and interviews, the facility failed to notify the physician of a change in condition after a resident developed blisters after an incident with spilled hot soup for 1 of 4 residents reviewed for Accidents (Resident #203 [R203]).

Inspectors wroteBased on record review and interview, the facility failed to obtain recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination-Maine Summary of Findings for 1 of 2 sampled resident's reviewed for PASRR evaluation (Resident #90 [R90]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a resident with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination for 1 of 3 residents reviewed for PASRR (Resident #24 [R24]).

Inspectors wroteBased on observations, interviews and record review, the facility failed to provide recommended nutritional services to 1 of 1 resident (Resident #258 [R258]) observed during mealtimes for 1 of 3 lunch meals observed (3/3/25, lunch).

Inspectors wroteBased on record review and interview, the facility failed to follow up on pharmacist recommendations timely, for 1 of 5 residents reviewed for unnecessary medications (Resident #53 [R53]).

Inspectors wroteBased on observation and interview, the facility failed to ensure medications were labelled, stored at the appropriate temperature, and secured properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications on 1 of 3 survey days (3/5/25).

Inspectors wroteBased on record reviews and interviews, the facility failed to obtain dental services for a resident with broken teeth for 1 of 1 residents reviewed for dental services (Resident #8 [R8]).

Inspectors wroteBased on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), included current diagnosis, and was updated for 1 of 6 residents reviewed (Resident #52 [R52]).

Inspectors wroteBased on interviews and record review, the facility failed to follow Physician orders for 1 of 1 sampled Resident receiving dialysis. (Resident #203, [R203]) and 1 of 2 sampled residents reviewed with insulin parameters [R21].

Inspectors wroteBased on record review and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to tube feedings, for 1 of 1 sampled resident reviewed with a feeding tube (Resident#39 [R39]).

Inspectors wroteBased on record review and interview, the facility failed to ensure that a physician's order for Ambien (a medication used to treat insomnia) was available and administered for 1 of 1 sampled residents (Resident #11[R11]).

Inspectors wroteBased on record review and interview, the facility failed to ensure the pharmacist identified an irregularity for as needed (PRN) psychotropic medication use for 1 of 5 residents reviewed for unnecessary medications (Resident#35 [R35]).

Inspectors wroteBased on record review and interview, the facility failed to ensure the physician examined a resident to determine if an as needed (PRN) anti-psychotic medication was still needed before writing a new order to renew the same PRN anti-psychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident#35 [R35]).

Inspectors wroteBased on observations, record reviews, and interview, the facility failed to be free of medication error rate of 5% or more. There were a total of 2 medication errors out of 28 opportunities for (Resident #57 [R57]) and (Resident #[R205]). The medication error rate was 7.14%.

Inspectors wroteBased on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use, and tube feeding supplies were stored in a sanitary manner in 1 of 2 medication rooms reviewed (Medication Storage Room on Wing B).

Inspectors wroteBased on observation and interview, the facility failed to implement appropriate infection prevention at point-of-care testing when Certified Nurse Assistant #2 (CNA2) did not apply gloves for a fingerstick procedure during blood glucose testing for 1 of 1 observation (2/15/24).

Inspectors wroteBased on review of the facility's 'Influenza Immunization Policy,' admission Influenza Consent form and interview, the facility failed to provide the Resident and/or the Resident's Representative with the Vaccine Information Statement (VIS)' prior to immunizing a resident with the influenza vaccine for all residents receiving the influenza vaccine who are not new admissions.

Inspectors wroteBased on record review and interview, the facility failed to revise and implement an individualized person-centered care plan to render trauma informed care to a resident with a personal history of trauma related to verbal abuse and bullying for 1 of 1 residents reviewed (Resident #1).

Inspectors wroteBased on facility reported incident and investigation, record review, facility policy review, and interviews, the facility failed to supervise a resident safety and complete a new elopement risk evaluation/assessment after a resident received a new power wheelchair and expressed the desire to leave the facility and go to the store. This failure enabled the resident to leave the facility's grounds without staff knowledge or supervision and cross a 3 lane street for 1 of 1 incidents reviewed (10/5/23).