Brownfield Rehabilitation and Care Center

Inspectors wroteThe facility failed to ensure 8 confidential residents were provided, the Grievance Procedure, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. Based on observation, interview, and record review, the facility failed to provide information to resident's and their representatives on their rights related to filing grievances or concerns for 8 of 28 confidential residents. The facility failed to ensure 8 confidential residents were provided, the Grievance Procedure, were provided information in regards to who the facility grievance officer was, their contact information, how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in one of one kitchen reviewed for dietary services. 1) The facility failed to ensure foods were labelled & dated. 2) The facility failed to protect foods from potential contamination. 3) The facility failed to ensure foods were stored under sanitary conditions. These failures could place residents at risk for food-borne diseases.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition in 1 of 1 laundry room in that:1. The facility failed to maintain clean lint traps in 1 of 2 dryers in the laundry room by failing to clean the lint traps per policy. This failure could place residents at risk for fire emergencies.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide 80 square feet of floor space per resident in 24 of 24 semiprivate resident rooms containing two beds (Rooms 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34). Rooms 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34 semi- private rooms did not have 80 square feet per resident. This failure could result in overcrowding in resident rooms and possible diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. The [NAME] failed to ensure food was accurately dated and labeled (3 cups of milks in the refrigerator). The DM failed to wash her hands when entering the food preparation area. The DM failed to ensure that spoiled food (potatoes) was properly discarded. The DM failed to ensure that dented cans were not stored in with the remainder of food for resident consumption. The [NAME] failed to cover food that was not actively being served. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for 2 of 26 residents (Resident #11 & #13) reviewed for care plans as follows: Resident #11 did not have a care plan for urinary incontinence and psychosocial well-being. Resident #13 did not have a care plan for urinary incontinence and psychosocial well-being. These failures could place residents at risk of not receiving the care required to meet their Individualized needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #2). The facility failed to ensure guidelines from Resident #2's smoking assessment were followed to include wearing a smoking apron. The facility also failed to follow Resident #2's care plan indicating Resident #2 should be supervised while smoking. These failures could place the resident at risk of inadequate supervision and accidents which could result in injury. Findings Included: Record Review of Resident #2's face sheet dated 7/17/2024 documented a [AGE] year-old male admitted on [DATE] with diagnoses to include: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicated the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal for 1 of 26 residents (Residents #20) reviewed for pneumococcal immunizations. - The facility failed to document pneumococcal immunization status for Resident #20 These failures could place residents at risk for contracting a viral disease and cause respiratory complications and potential adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to follow their own established smoking policy for 1 of 1 smoking area (main building) reviewed for smoking policies. - The facility failed to ensure the designated smoking area was free from cigarette butt trash. These failures could affect residents by resulting in an environment that is not safe, sanitary, or comfortable for residents, staff, and visitors.

Inspectors wroteBased on record review, observation and interview, the facility failed to provide 80 square feet of floor space per resident in 24 of 24 semiprivate resident rooms containing two beds (Rooms 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34) reviewed for physical environment. Rooms 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34 semi- private rooms did not have 80 square feet per resident. This failure could result in overcrowding in resident rooms and possible diminished quality of life.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure resident had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 3 of 12 residents (Resident #10, #18, and #22) observed for physical restraints. Resident #10 failed to have consent and evaluation for scoop mattress for fall prevention. Resident #18 failed to have physician orders, consent and evaluation for a scoop mattress for fall prevention. Resident #22 failed to have consent and evaluation for bed and chair alarm for fall prevention. This failure put residents at risk of being restrained without justification of the need for a restraint.

Inspectors wroteBased on record interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 6 of 12 residents (Residents #1, 3, 7, 15, 20, and 23) reviewed for PASRR screening, in that: Residents #1, 3, 7, 15, 20 and 23 did not have an accurate PASRR Level 1 assessments when they had a diagnosis of major depressive disorder and schizoaffective disorder, bipolar type, bipolar disorder. These failures could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that certified nurse's aides had the appropriate competencies and skills sets to provide nursing services to provide resident needs and assure resident safety and attain or maintain the highest practicable wellbeing for 2 of 2 Residents (Resident #9 and #20) reviewed for incontinent care. The facility failed to ensure CNA A maintained appropriate technique and did not wipe Resident #9's buttocks on either side. The facility failed to ensure CNA C maintained appropriate technique and did not wipe Resident #20's left cheek and wiped buttocks from back to front. This failure had the potential to affect residents by placing them at an increased risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for two of two residents (Residents #9 and 20) and 3 of 3 CNAs (CNA A, B, and C) reviewed for infection control. CNA A failed to perform hand hygiene between glove changes when providing incontinent care for Resident #9. CNA B failed to perform hand hygiene between glove changes when providing incontinent care for Resident #20. CNA C failed to change dirty gloves while repositioning resident to side when providing incontinent care for Resident #20. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, in that 1 of 12 residents (Resident #5) continued to receive psychotropic medications PRN for more than 14 days without a physician addressing the continued use of the medication: - Resident #5 continued to have a PRN order for Lorazepam 0.5mg after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions.

Inspectors wroteBased on record review, observation and interview , the facility failed to provide 80 square feet of floor space per resident in 24 of 24 semiprivate resident rooms containing two beds (Rooms 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34). Rooms 1, 3, 4, 5, 7, 8, 9, 10, 11, 12, 13, 15, 18, 20, 22, 24, 26, 28, 29, 30, 31, 32, 33, and 34 semi- private rooms did not have 80 square feet per resident. This failure could result in overcrowding in resident rooms and possible diminished quality of life.