Brewster Convalescent Center

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain a comfortable air temperature in the resident living environment. This affected two residents (Resident #32, Resident #28) and had the potential to affect all 10 residents on the 500 unit. The facility was census was 57.

Inspectors wroteBased on record review, staff interview, review of facility policy, and observation, the facility failed to update the physician on a change of condition for Resident #38. This affected one (Resident #38) of one resident reviewed for changes in conditions. The facility census was 55.

Inspectors wroteBased on record review and interview, the facility failed to ensure interventions were implemented and monitored for Resident #33's trending weight loss. This finding affected one (Resident #33) of two residents reviewed for nutrition.

Inspectors wroteBased on interview, medical record review, and facility policy review, the facility failed to ensure pre-treatment and post-treatment monitoring was completed for a dialysis resident. This affected one (Resident #24) of two residents reviewed for dialysis. The facility census was 55.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure appropriate hand washing or hand sanitization was completed prior to completing Residents #1 and #33's non-pressure wound care. This affected two (Residents #1 and #33) of two residents reviewed for general skin conditions.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #24 and #42's medical records have the appropriate documentation of the education provided regarding the risks and benefits of the influenza and pneumococcal vaccines. This affected two (Residents #24 and #42) of five residents reviewed for immunizations.

Inspectors wroteBased on record review, review of policy, observation and interview, the facility did not ensure infection control practices were maintained during a wound treatment for Resident #9. This affected one resident (#9) of three residents reviewed for hospice. The facility census was 47.

Inspectors wroteBased on medical record review and interview, the facility failed to thoroughly assess and provide timely medical treatment to a resident with multiple fractures. This affected one resident (#31) of four residents reviewed for accidents. Actual harm occurred on 04/16/23 when Resident #31 fell, hitting her elbow on the shower chair and landing on her buttocks. At the time of the fall, Resident #31 complained of elbow pain and tailbone pain, however only the elbow pain was assessed, and physician notified resulting in the resident receiving an Xray of the shoulder and being diagnosed with a fractured humeral head on 04/17/23. The failure of the facility to appropriately assess and document the resident's sacral pain at the time of the fall resulted in a delay in the diagnosis and treatment of the resident's fractured sacrum until 04/20/23. [...]

Inspectors wroteBased on observation, medical record review, orthopedic consult review, therapy note review, and interview, the facility failed to manage Resident #31's pain adequately and within a timely manner. This affected one resident (#31) of one resident reviewed for pain management. The facility census was 51. Actual harm occurred on 04/16/23 to Resident #31, who had sustained a fall with fractured left humeral head and sacrum, when staff failed to adequately address the resident's pain resulting in Resident #31 having a decline in her activities of daily living. The facility also failed to administer pain medications timely when staff were notified Resident #31 was crying out in pain during therapy sessions and was declining to participate in therapy services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure clean and sanitary kitchen area and ensure appropriate glove use by kitchen staff. This had the potential to affect all residents receiving meals from the facility kitchen. The facility identified one resident (#38) as not receiving meals from kitchen for Nothing by Mouth (NPO) status. The facility census was 51.

Inspectors wroteBased on interview, record review, and review of PBJ (Payroll Based Journal) data report the facility failed to ensure accuracy of PBJ information. This had the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on observation, interview, record review, and review of facility policy the facility failed to identify a pattern of urinary tract infections (UTIs) did not occur for ten residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) residing in the same nursing unit, the facility failed to ensure appropriate use of personal protective equipment (PPE) for resident (#308) on droplet precautions, and failed to ensure documentation of education for hand hygiene, gloves and cleansing of perineal area. This affected ten residents (#13, #18, #23, #34, #38, #41, #50, #156, #158 and #256) of 16 residents reviewed for UTIs, one (#308) out of four residents reviewed for transmission based precautions. The facility census was 51.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program in the kitchen area. This had the potential to affect all residents receiving meals from the facility kitchen. The facility identified one Resident (#38) as not receiving meals from kitchen for Nothing by Mouth (NPO) status. The facility census was 51.

Inspectors wroteBased on observation, interview, record review, review of facility policy, and manufacturer's recommendations the facility failed to ensure open bottles of insulin for Resident's #17, #47, and #256 were dated. This had the potential to affect nine resident's (Resident's #3, #15, #17, #18, #24, #43, #48, #156, #256) requiring insulin who resided in the facility. The facility census was 51.

Inspectors wroteBased on record review, facility policy review and interview the facility failed to ensure Resident #54's Do Not Resuscitate (DNR) advance directives/order was honored. This affected one resident (#54) of three reviewed for DNR advanced directives. The facility census was 50.

Inspectors wroteBased on interview and record review, the facility failed to develop care plans for a resident with pressure ulcers and included a resident's code status. This affected two residents (#17, #27) of 20 residents reviewed for care planning. The facility census was 51.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure a resident was assisted to the bathroom timely. This affected one resident (#15) of three residents reviewed for activities of daily living (ADL) assistance. The facility census was 51.

Inspectors wroteBased on interview and record review, the facility failed to monitor a dialysis fistula site for a resident receiving dialysis. This affected one resident (#48) of one reviewed for dialysis treatments. The facility identified one resident as receiving dialysis treatments. The facility census was 51.

Inspectors wroteBased on record review, policy review, and interview, facility failed to send a referral to speech therapy after Resident #27 experienced a choking episode which required a downgrade in diet texture. This affected one resident (#27) of two residents reviewed for nutrition. The facility census was 51.

Inspectors wroteBased on observation, review of the medical record, interviews with staff, and review of the facility policy the facility failed to prevent the development of a pressure ulcer for Resident #28. Actual harm occurred when Resident #28 developed an avoidable, in house acquired, stage three (full thickness wound with fat and tissue exposed) pressure ulcer to the left outer ankle. This affected one (Resident #28) of three residents reviewed for pressure ulcers. The facility census was 42.

Inspectors wroteBased on record review and interview the facility failed to ensure State Tested Nurse Aides (STNA) received at least 12 hours of training annually including dementia care training. This had the potential to affect all 42 residents currently residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure the Facility Assessment (FA) was comprehensive and reviewed annually as required. This had the potential to affect all 42 residents currently residing in the facility.

Inspectors wroteBased on record review and interview the facility failed to ensure a comprehensive program to reduce and/or eliminate Legionella bacteria. This had the potential to affect all 42 residents currently residing in the facility.

Inspectors wroteBased on medical record review, policy review, review of infection control tracking logs, and interview, the facility failed to ensure residents who received antibiotic orders were reviewed for appropriateness of use in a timely manner to permit communication with the physician regarding those residents who did not meet criteria of infections. The facility also failed to involve the pharmacist in the antibiotic stewardship program after multiple residents were treated with antibiotics without criteria for infections being met. This affected one (Resident #31) of two residents reviewed for urinary tract infections and had the potential to affect all 41 other residents currently residing in the facility. The facility census was 42.

Inspectors wroteBased on record review, observation and staff interviews the facility failed to ensure a medication error rate below five percent. Observation of 37 medications administered with two medication errors resulted in a medication error rate of 5.4 percent. This affected two (Residents #9 and #28) of six residents observed for medication administration.

Inspectors wroteBased on medical record review and staff interview the facility failed to ensure the physician was notified of a change in status of a pressure ulcer for Resident #28. This affected one (Resident #28) of three residents reviewed for pressure ulcers.

Inspectors wroteBased on medical record review, policy review, and interview the facility failed to implement a bowel protocol for two (Residents #10 and #33) of five residents reviewed for medication use.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident #33 had planned interventions in place and was properly assessed to ensure new interventions were implemented after falls and failed to ensure staff utilized a gait belt for ambulation with Resident #195 as planned. This affected one of two residents reviewed for falls and one additional resident observed during ambulation.

Inspectors wroteBased on observation, review of the medical record and interviews with staff the facility failed to ensure Resident #12 had her oxygen on as ordered. This affected one (Resident #12) of two residents reviewed for respiratory therapy.

Inspectors wroteBased on observation, review of the medical record, interview with staff, and review of Medscape website the facility failed to ensure Synthroid was given at least four hours before any other medications per manufacturer's recommendations. This affected three (Resident #9, #25, and #28) of six residents reviewed for unnecessary medications.

Inspectors wroteBased on medical record review, policy review, and interview the facility failed to ensure a resident receiving psychotropic medications had time limits for the use of anti-anxiety medication ordered on an as necessary basis and failed to ensure a physician provided rationale for refusal of gradual dose reductions of psychotropic medication. This affected one (Resident #10) of five residents reviewed for medication use.