Brewster Health Center

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to label Resident (R) 31 and R42's insulin (a hormone that lowers the level of glucose in the blood) flex pens when initially opened for use and when expired. This deficient practice placed the affected residents at risk for ineffective medications.

Inspectors wrote- R25's Electronic Medical Record (EMR) recorded diagnoses of dementia (a progressive mental disorder characterized by failing memory and confusion) and anxiety (mental or emotional reaction characterized by apprehension, uncertainty, and irrational fear). R25's Quarterly Minimum Data Set (MDS), dated [DATE], recorded R25 had severely impaired cognition. The MDS recorded R25 required staff assistance with most activities of daily living (ADL). The MDS recorded the resident received antipsychotic medication during the observation period. The Psychotropic Drug Use Care Area Assessment (CAA), dated 08/30/24, recorded R25 received antipsychotic medication and had dementia, anxiety, and depression diagnoses. R25's Care Plan, dated 05/21/25, recorded R25 received antipsychotic medication for the diagnosis of dementia with behaviors and staff were to monitor for side effects and effectiveness. [...]

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents, with one reviewed for abuse. Based on observation, record review, and interview, the facility failed to ensure staff reported and investigated the physical incident between R63 and R66. This placed the residents at risk for ongoing abuse and/or mistreatment.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on interview and record review, the facility failed to notify the State Long term Care Ombudsman (LTCO) of Resident (R) 34's facility-initiated discharge to the hospital. This placed R34 at risk for impaired rights.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to develop a comprehensive plan of care for Resident (R) 28 for Care Area Assessments (CAA) triggered from the Minimum Data Set (MDS). This placed R28 at risk for resident-centered unmet care needs.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to revise the care plan with interventions to prevent falls for Resident (R) 67 and R70. This placed the residents at risk for injuries due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents, of which six were reviewed for falls. Based on observation, record review, and interview, the facility failed to identify and implement interventions to prevent falls for Resident (R) 28, R67, and R70. This placed the resident at risk for ongoing falls and injuries.

Inspectors wroteThe facility had a census of 75 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to adhere to infection control for enhanced barrier precautions (EBP - an infection control intervention designated to reduce transmission of resistant organisms that employs targeted gown and glove used during high contact resident care activities) for Resident (R) 57 who had a coccyx wound ( pressure ulcer (localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and/or friction). This placed the resident at risk for possible exposure to infection.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents. Based on record review and interview, the facility lacked evidence the required committee members attended the Quality Assessment and Assurance (QAA) Committee quarterly meetings. This placed the residents who resided in the facility at risk for decreased quality of care.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to develop a complete baseline care plan for Resident (R)226 which included instructions to staff regarding R226's fluid restriction (limitation of amount of liquid consumed each day). The facility also failed to include information to staff regarding R226's hospice services. This placed the resident at risk for uncommunicated care needs.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents. Based on observation, interview, and record review, the facility failed to revise the care plan interventions related to Resident (R)48's diagnoses and medications, and for R52's dental orders. This deficient practice placed the residents at risk for impaired care due to uncommunicated care needs.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents, with four reviewed for nutrition. Based on observation, interview and record review, the facility failed to monitor and record Resident(R)226's physician ordered fluid restriction (limitation of amount of liquid consumed each day). This placed the resident at risk for complications from fluid overlaod.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents with one reviewed for respiratory care. Based on observation, interview, and record review, the facility failed to obtain a current physician order for the use of supplemental oxygen for Resident (R)42 and failed to ensure staff provided care for R42's oxygen equipment including the tubing, humidifier and filter. The facility further failed to care plan R42's use of the supplemental oxygen. This deficient practice placed R42 at risk for respiratory issues related to oxygen use.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents with five reviewed for unnecessary medication. Based on observation, interview, and record review, the facility failed to monitor targeted behaviors related to the use of antipsychotic drugs (class of medications used to treat major mental conditions which cause a break from reality) for Resident (R) 67, placing the resident at risk for unnecessary psychotropic ( altering mood or thought) drugs.

Inspectors wroteThe facility had a census of 76 residents. The sample included 18 residents. Based on observation, record review, and interview, the facility failed to ensure the daily staff nursing hours were posted for one day of the onsite survey.

Inspectors wroteThe facility had a census of 71 residents. The sample included 19 residents. Based on observation, record review, and interview the facility failed to prepare, store, distribute, and serve food under sanitary conditions for the 71 residents in the facility who received their meals from the facility kitchen. This placed the residents at risk for foodborne illness.

Inspectors wroteThe facility had a census of 71 residents. The sample included 19 residents with two reviewed for dignity. Based on observation, record review, and interview the facility staff failed to treat Resident (R)30 and R51 with dignity, when staff failed to cover their urinary catheters (insertion of a catheter into the bladder to drain the urine into a collection bag) with a privacy bag leaving the urine collection bag visible to other residents and guests in the facility. This placed the resident at risk for impaired psychosocial well-being. Findings Included: - R30's Electronic Medical Record (EMR) documented she had diagnoses of hemiplegia (paralysis of one side of the body), hemiparesis (muscular weakness of one half of the body), and urinary retention (lack of ability to urinate and empty the bladder). [...]

Inspectors wroteThe facility had a census of 71 residents. The sample included 19 residents with six reviewed for unnecessary medications. Based on observation, record review and interview, the facility's consultant pharmacist (CP) failed to notify the Director of Nursing (DON), medical director, or physician about an inappropriate diagnosis for the use of an antipsychotic medication (medication used to treat significant mental health problems, and/or the facility failed to act upon the pharmacist recommendations for two sampled residents, Resident (R) 36 and R51. This placed the residents at risk to receive unnecessary antipsychotic medications and have adverse side effects.

Inspectors wroteThe facility had a census of 71 residents. The sample included 19 residents with six reviewed for unnecessary medications. Based on observation, record review and interview, the facility failed to ensure an appropriate diagnosis for the use of an antipsychotic medication (medications used to treat significant mental health problems) for two sampled residents, Residents (R) 36 and R51. This placed the residents at risk to receive unnecessary antipsychotic medications and have adverse medication side effects.