Brunswick Health & Rehab Center

Inspectors wroteBased on record review and staff, Nurse Practitioner (NP) and Medical Director interviews, the facility failed to complete and document comprehensive assessments and failed to identify or recognize the significance of severe pain and changes in mobility, transfers and ambulation after the resident reported an unwitnessed fall. The NP was notified of the resident's hip pain on 7/15/25 and evaluated the resident but was not informed of the unwitnessed fall on 7/14/25. The NP indicated had he known Resident #61 had fallen and was reporting pain, he would have ordered x rays immediately. The NP was notified again on 7/18/25 the resident was reporting hip pain and an x-ray of the resident's bilateral hips was ordered. [...]

Inspectors wroteBased on record review and interviews with staff, Nurse Practitioner (NP) and Physician, the facility failed to ensure pain management was provided to Resident #61, who had severe cognitive impairment and was unable to verbalize the need for pain medication, following an unwitnessed fall on 7/14/25 that resulted in changes in the level of transfer assistance she needed for toileting and moving from chair to bed. Communication from the nursing staff to the Nurse Practitioner on 7/15/25 failed to include Resident #61 had an unwitnessed fall. The NP did not assess the lower extremities for pain and concluded that the source of the hip pain was nerve pain. The NP's plan was for staff to administer acetaminophen 650 milligrams for pain as previously ordered and educate the severely cognitively impaired resident to request pain medication. [...]

Inspectors wroteBased on observation, record review and resident and staff interviews, the facility failed to determine whether self-administration of medications was clinically appropriate for 1 of 1 resident reviewed for self-administration of medications (Resident #7).

Inspectors wroteBased on observations, record review, and interviews with staff, residents, and Nurse Practitioner, the facility failed to transfer Resident #72 with a slide board according to the care plan, placing the resident at risk for avoidable injury. On 5/25/25, Nurse Aide #9 transferred Resident #72 from the wheelchair to the bed without using the slide board. This deficient practice was identified for 1 of 2 residents reviewed for accidents (Resident #72).

Inspectors wroteBased on record review, observations and resident, staff and Registered Dietitian (RD) interviews, the facility failed to maintain the ordered fluid restrictions, renal diet restrictions and provide double portions of protein per the physician order for 1 of 1 sampled resident receiving hemodialysis (Resident #7).

Inspectors wroteBased on observation, record review and staff, resident and Physician interviews, the facility failed to ensure the medications were administered to the resident which had the potential for an adverse outcome for 1 of 1 resident observed with medication left at the bedside (Resident #7).

Inspectors wroteBased on observation, record review and resident, staff and Registered Dietitian (RD) interviews, the facility failed to provide food that accommodated a documented allergy to tomatoes for 1 of 5 residents reviewed for nutrition (Resident #7).

Inspectors wroteBased on record review and responsible party (RP), staff, Medical Director, and Nurse Practitioner (NP) interviews, the facility failed to assess, diagnose and medically treat a resident who was presenting with signs of Clostridium Difficile (C. difficile) (According to the Centers for Disease Control and Prevention: C. difficile-is a highly contagious bacteria that causes diarrhea and inflammation of the colon, can be life-threatening and present with symptoms which include loose stools, abdominal cramping, loss of appetite and stools may have a foul odor). The facility failed to identify the seriousness of the symptoms of abdominal discomfort, frequent loose stools with foul odor, tiredness, loss of appetite, and inability to get out of bed and implement effective interventions. [...]

Inspectors wroteBased on record review and interviews with staff, the resident's Responsible Party (RP), Medical Director, and Nurse Practitioner (NP), the NP failed to communicate and collaborate with the Medical Director for a resident (Resident #290) who was presenting with signs of Clostridium Difficile (C. difficile or C. diff) According to the Centers for Disease Control and Prevention: C. diff-is a highly contagious bacteria that causes diarrhea and inflammation of the colon, can be life-threatening and present with symptoms which include loose stools, abdominal cramping, loss of appetite and stools may have a foul odor. For the period of [DATE], date of admission, through [DATE], the first date the NP had a progress note for Resident #290, the resident was recorded as having 42 stools in 24 days. [...]

Inspectors wroteBased on record review, and resident and staff interviews, the facility failed to ensure residents' rights to maintain dignity for 2 of 2 residents reviewed for dignity. On the night of admission, Resident #242 informed Nurse Aide (NA) #9 she needed to use the bathroom, and NA #9 told her to just go in the bed. This resulted in the resident having to urinate in the bed, crying, and making her feel useless, bad and embarrassed. Additionally, NA #9 provided incontinence care to Resident #75 while he was in his room, standing up over his wheelchair, holding onto a walker. Resident #75 felt this was rude and insensitive.

Inspectors wroteBased on observations, record review and staff interviews the facility failed to remove expired food items stored for use in the dry storage room and remove expired food items from 1 of 2 nourishment rooms. This practice had the potential to affect the food served to 92 out of 92 residents.

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to: 1) remove expired medications in accordance to the manufacturer's expiration date for 1 of 3 medication carts (Medication Cart #4); 2) remove loose pills of various sizes, colors, and shapes from 2 of 3 medication carts (Medication Cart #2 and Medication Cart #4); and 3) failed to secure medications observed at the bedside for 1 of 1 severely cognitively impaired resident (Resident #59) reviewed for medication storage.

Inspectors wroteBased on record review, and staff, Responsible Party (RP) and Medical Director interviews, the facility failed to communicate complete resident medical information to the receiving hospital for 1 of 1 resident reviewed for hospitalization (Resident #290).

Inspectors wroteBased on observations, record review, and staff, resident, and Medical Director interviews, the facility failed to have an effective system in place for communicating a therapy order for a left hand splint to nursing staff for 1 of 1 resident (Resident #71) reviewed for a contracture and limited range of motion.

Inspectors wroteBased on observations, record review, and resident and staff interviews, the facility failed to provide care in a safe manner during the provision of incontinence care resulting in the resident being lowered to the floor. This occurred for 1 of 3 residents reviewed for falls (Resident #73).

Inspectors wroteBased on observations, record review, and staff and Medical Director interviews, the facility failed to maintain a resident's indwelling urinary catheter below the resident's bladder when the Wound Treatment Nurse placed the indwelling urinary catheter on the resident's bed during a sacral pressure ulcer dressing change and failed to cleanse the urethral meatus and catheter tubing during catheter care in a manner to prevent contamination/infection for 1 of 1 resident observed for urinary catheters (Resident #66).

Inspectors wroteBased on observations, record review, and staff, Consulting Pharmacist, Psychiatric Physician Assistant, and the Medical Director interviews the facility failed to ensure an antianxiety medication was available from the pharmacy to administer as ordered by the physician resulting in 3 missed doses for 1 of 5 residents (Resident #53) reviewed for medication administration.

Inspectors wroteBased on record review and Nurse Practitioner (NP), Medical Director, Consulting Pharmacist, Pyschiatric Physician Assistant, and staff interviews, the facility failed to prevent significant medication errors for 2 of 6 residents (Resident #241 and Resident #53) whose medications were reviewed. Nurse #12 administered medications to Resident #241 that were prescribed for Resident #295. The medications included amlodipine (used to treat blood pressure)/ valsartan (used to treat blood pressure), carvedilol (beta blocker used to treat blood pressure), duloxetine (used to treat depression), gabapentin (used to treat pain), memantine (used to treat dementia) and roflumilast (used to treat inflammation in chronic obstructive pulmonary disease). Resident #241 had no significant adverse effects as a result of the error. [...]

Inspectors wroteBased on observations, record review, and staff interviews, the facility failed to implement the facility's infection control policy and procedures for Enhanced Barrier Precautions (EBP) when the Wound Nurse provided wound care for Resident #81's chronic wounds wearing gloves but no gown. This occurred for 1 of 3 staff observed for infection control practices (Wound Nurse).

Inspectors wroteBased on observations, record review, staff and Physician interviews, the facility failed to administer eye drops as prescribed to a resident (Resident # 35) resulting in 9 extra doses of an eye drop that was prescribed for post cataract surgery care. The deficient practice was found for 1 of 5 residents reviewed for unnecessary medications.

Inspectors wroteBased on record review and staff interviews the facility failed to implement their abuse policy for facility staff to immediately report an allegation of abuse when two staff members failed to report an allegation of staff (Nurse #12) to resident abuse to the facility management as soon as the incident was observed. This occurred for 1 of 3 residents (Resident #16) reviewed for abuse.

Inspectors wroteBased on record review and staff interviews, the facility failed to develop a comprehensive care plan that addressed Hospice care for 1 of 4 sampled residents reviewed for hospice (Resident #18).

Inspectors wroteBased on observations, record review, staff interviews, and the manufacturer's guidelines, the facility failed to dispose of an expired bottle of insulin in 1 of 2 medication storage rooms observed for medication storage (medication storage room [ROOM NUMBER]-hall). The facility also failed to label with a name and opened date a bottle of nasal spray and failed to discard an expired bottle of eye drops on the 800-hall medication cart for 2 of 4 medication carts reviewed for medication storage.

Inspectors wroteBased on record review, and staff interviews the facility failed to ensure laboratory services were followed up with when results for a STAT (immediately) urine culture and sensitivity laboratory test was not received resulting in the need for a repeat urine specimen to be collected and a delay in receiving antibiotic treatment for a urinary tract infection. This deficient practice occurred for 1 of 1 resident (Resident #19) reviewed for laboratory services.

Inspectors wroteBased on observation, Responsible Party and staff interviews, and record review, the facility failed to provide radiology services to meet the resident's needs and to inform the physician when a routine x-ray order for the resident's left hip, left femur (thigh bone), left knee, and left tibia/fibula (the two long bones located in the lower leg) was delayed beyond the expected timeframe for 1 of 1 resident reviewed for radiology services.

Inspectors wroteBased on record review and staff interviews, the facility failed to maintain communication and coordination of services provided by Hospice in the medical record complete with Hospice admission documentation, Hospice plan of care, and Hospice visit notes in the facility's electronic medical record and failed to obtain physician orders for Hospice services for 2 of 4 residents reviewed for Hospice, (Resident #18 and #36).

Inspectors wroteBased on record review and staff interviews, the facility's Quality Assurance and Performance Improvement (QAPI) program failed to maintain implemented procedures and monitor interventions the committee put in place following the recertification and complaint investigation survey completed on 09/02/22. This was for a deficiency cited in the area of Developing and Implementing Comprehensive Care Plans (F656) that was subsequently recited during the recertification and complaint investigation survey of 12/21/23. The continued failure during two federal surveys of record shows a pattern of the facility's inability to sustain an effective QAPI program.

Inspectors wroteBased on record review and staff interviews, the facility failed to provide written notification of discharge or transfer to the resident and their Responsible Party (RP) of the reason for discharge to the hospital for 1 of 1 sampled resident (Resident #90) reviewed for hospitalization.

Inspectors wroteBased on observations, record review, staff, Psychiatric Social Worker, Nurse Practitioner, Medical Director, and Psychiatric Physician's Assistant interviews the facility failed to protect a resident's right to be free from mental abuse by a visitor when the visitor was found to have posted a video recording of a cognitively impaired resident that included a caption with a demeaning comment, and the visitor was heard on the video mocking and ridiculing the resident while the resident was lying in bed and exhibiting behaviors of yelling out. This occurred to 1 of 1 Resident (Resident #1) reviewed for visitor to resident abuse. The video was posted on two social media platforms. This action would have caused a reasonable person psychosocial harm such as feelings of shame, humiliation, agitation, and degradation.

Inspectors wroteBased on record review, staff, Physician and Consultant Pharmacist interviews, the monthly Medication Regimen Reviews for May, June, and July 2023 failed to identify the omission of the thyroid medication, levothyroxine from the orders entered following readmission to the facility on 5/8/23 for a resident with known diagnosis of hypothyroidism (Resident #2) resulting in 108 missed doses for 1 of 3 residents reviewed for medication errors.

Inspectors wroteBased on record review and staff, Physician and Consultant Pharmacist interviews, the facility failed to accurately transcribe and administer a thyroid medication, levothyroxine, listed on the discharge medication summary list resulting in the medication not administered from 5/8/23 through 8/25/23 for a total of 108 missed doses for 1 of 3 residents (Resident #2) reviewed for medication error.