Brush Hill Care Center

Inspectors wroteBased on record review and interview, it was determined the facility failed for one Resident (#10), out of a total sample of 25 residents, to refer to the state-designated authority for further evaluation of the diagnosis of a serious mental illness (SMI). This deficient practice has the potential to impact residents who are diagnosed with major mental illness, intellectual disability or related conditions if a state-designated authority did not evaluate a resident's mental health needs.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure the resident environment remained free of unattended and unsecured medications for one Resident (#51), out of a total sample of 25 residents and for residents residing on the second-floor unit. Specifically, the facility failed:1. For Resident #51, to ensure medications were not kept at the bedside while staff were not present in a unit with known wandering residents; and2. For residents on the second-floor unit, to ensure medications were kept in a locked medication cart while staff were not present in the hallway.

Inspectors wroteBased on records reviewed and interviews, for one Resident (#1), out of a total sample of 25 residents, the facility failed to ensure that his/her drug regime was free from unnecessary drugs. Specifically, for Resident #1, the facility failed to implement the ophthalmologist's (eye physician) recommendations resulting in Resident #1 receiving an excessive duration of eye drops.

Inspectors wroteBased on observation and interview, the facility failed to store food from outside sources safely to prevent potential foodborne illness for one Resident (#121), out of a total sample of 22 residents.

Inspectors wroteBased on observations and interviews, the facility failed to ensure it was administered in a manner that enabled it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to effectively manage and utilize their administrative team and stay up to date with current Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and Massachusetts Department of Public Health (MDPH) guidance.

Inspectors wroteBased on document review and interview, the facility failed to develop and implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to: 1. Ensure active involvement of all required members when conducting the facility assessment; and 2. Implement the identified competency-based training as indicated.

Inspectors wroteBased on record review and interview, the facility failed to ensure the designated Infection Control Nurse (ICN) adequately assessed, developed, implemented, monitored, and managed the infection prevention and control program. Specifically, the ICN failed to: 1. Ensure enhanced barrier precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) were implemented; and 2. Implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program.

Inspectors wroteBased on interviews and staff education records reviewed for five direct care staff employees (Nurse #14, Nurse #15, Nurse #16, Nurse #17 and Nurse #18) of five employees reviewed, the facility failed to ensure that training on behavioral health was included as mandatory training for direct care staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement an individualized, person-centered care plan to meet the physical, psychosocial, and functional needs for four Residents (#5, #112, #14, and #2), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #5, a comprehensive care plan was developed and implemented to address the Resident's constipation; 2. For Resident #112, a comprehensive care plan was developed to address the use of antipsychotic medication that identified target behaviors and individualized, measurable non-pharmacological interventions and measurable goals of treatment; 3. For Resident #14, a comprehensive care plan was a. implemented to monitor for adverse consequence (side effects) of antidepressant medications; and b. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for seven Residents (#5, #68, #19, #73, #85, #76 and #92), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Residents #5, medication reconciliation process was conducted thoroughly and included all medications approved by the physician upon readmission to the facility, and as needed (PRN) interventions implemented according to physician's orders to potentially prevent hospital intervention to treat constipation, and failed to consistently monitor the Resident's response to interventions to prevent constipation; 2. For Resident #68, all components of wound recommendations were implemented; 3. For Resident #19, implement recommendations from the Wound Consultant; 4. [...]

Inspectors wroteBased on observation and interviews, the facility failed to ensure its staff provided a meaningful and engaging activity program for residents residing on one Unit (3A), out of four units in the facility. Specifically, the facility failed to ensure residents were involved in activities.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement nutritional interventions as ordered to maintain acceptable parameters of nutritional status for one Resident (#90), with an unplanned gradual weight loss, in a total sample of 24 residents. Specifically, the facility failed to provide as needed nutritional supplements when his/her meal intake was less than 50% as ordered.

Inspectors wroteBased on interview and record review, the facility failed to ensure staff implemented dialysis care and services consistent with professional standards of practice for two Residents (#19 and #76), out of 24 sampled residents. Specifically, the facility failed to provide ongoing communication between the nursing facility and dialysis facility.

Inspectors wroteBased on record review and interview, the facility failed to ensure that as needed (prn) orders for psychotropic medications were limited to 14 days, unless otherwise documented by the attending physician or prescribing practitioner that it was appropriate to extend beyond 14 days for three Residents (#31, #112, and #173), out of a total sample of 24 residents. Specifically, the facility failed to ensure: 1. For Resident #31, that the prn order for Ativan (antianxiety) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; 2. For Resident #112, that the prn order for Valium (hypnotic) was limited to 14 days and was reviewed by the Physician with a documented rationale for its continued use; and 3. [...]

Inspectors wroteBased on observation, test tray results, and interview, the facility failed to ensure staff served food that was palatable and at an appetizing temperature for 1 out of 2 test trays conducted.

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to follow professional standards of practice for food safety and sanitation to prevent the potential spread of foodborne illness to residents who are at high risk. Specifically, the facility failed to maintain the ice machine in a clean and sanitary manner in three out of four kitchenettes.

Inspectors wroteBased on observation, interview, and policy review, for five Residents (#68, #173, #112, #31, and #19), of 24 sampled residents, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and potential transmission of communicable diseases and infections. Specifically, the facility failed to implement Enhanced Barrier Precautions (EBP, an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employs targeted gown and glove use during high contact resident care activities) for the following Residents: A. For Resident #68, who has chronic wounds, putting him/her at increased risk for infection; B. For Resident #173, who has wounds and a gastrostomy tube; C. For Resident #112, who has a gastrostomy tube and a tracheostomy; D. [...]

Inspectors wroteBased on document review and interview, the facility failed to implement an Antibiotic Stewardship Program to promote and monitor the appropriate use of antibiotics which are used to guide decisions for evaluating antibiotic prescribing patterns in accordance with the Antibiotic Stewardship Program.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a reasonable accommodation was made for one Resident (#68), of 24 sampled residents. Specifically, the facility failed to ensure the call system was accessible to the Resident to call for staff assistance.

Inspectors wroteBased on observation, interview, record review, and policy review, the facility failed to review and revise the care plan for one Resident (#31), out of a total sample of 24 residents. Specifically, the facility failed to ensure the care plan was updated to reflect the discontinuation of anticoagulant therapy (medication to break down existing clots or prevent clots from forming).

Inspectors wroteBased on observations, interviews, and policy review, the facility failed to maintain an environment free of accident hazards. Specifically, the facility failed to ensure smoking material was stored securely for one Resident (#100), out of 17 identified facility smokers, out of 24 sampled residents.

Inspectors wroteBased on record review and interview, the facility failed to assess a history of trauma and failed to assess and to develop a plan of care accounting for Resident's experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for one Resident (#31), with a history of trauma, out of a total sample of 24 residents.

Inspectors wroteBased on interview and record review, the facility failed to act promptly upon recommendations made by the Consultant Pharmacist during the monthly Medication Regimen Reviews (MRR) for two Residents (#10 and #69), out of a total sample of 24 residents. Specifically, the facility failed to act on the consultant pharmacist's recommendations to obtain labs in order to help assess the efficacy of medications.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure all drugs and biologicals were stored in a safe and secure manner as required. Specifically, the facility failed for one Resident (#173), out of a total sample of 24 residents, to ensure medicated mouthwash was not left unsecured and unattended in the Resident's room.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain accurate medical records in accordance with professional standards and practices for two Residents (#19 and #112), out of a total sample of 24 residents. Specifically, the facility failed: 1. For Resident #19, to document weekly comprehensive skin assessment per physician orders; and 2. For Resident #112, to ensure a diagnosis of allergic dermatitis from adhesives, diagnosed by the facility's consultant wound physician, was prominently documented in the medical record as an allergy.

Inspectors wroteBased on record reviews and interview, the facility failed to ensure their abuse policy included written procedures for screening potential employees for a history of abuse, neglect, exploitation, or misappropriation of resident property as required.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure staff implemented and followed their Abuse Policy, when on 12/27/23 Resident #2 reported to a staff member that Resident #1 had acted in a sexually inappropriate manner towards him/her, and although several staff members became aware of the allegation, they did not report the allegation to administration until the following day.

Inspectors wroteBased on records reviewed and interviews, for one of three sampled residents (Resident #2), who had severe cognitive impairment and was dependent on staff to meet his/her care needs, the Facility failed to ensure that after being made aware on 12/28/23 of an allegation of an unwanted sexual advance made by Resident #1 toward Resident #2 that occurred on 12/27/23, that they obtained and maintained evidence that a thorough investigation was completed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop a care plan for one Resident (#141), and implement care plans for 6 Residents (#118, #23, #13, #142, #19 and #62), out of a sample of 40 residents. Specifically, the facility failed: 1. For Resident #141, to develop a care plan to address wandering behavior resulting in a resident-to-resident altercation where the Resident sustained a laceration and skin tears; 2. For Resident #118, to provide supervision with meals per the care plan; 3. For Resident #23, to ensure he/she wore a boot per the physician's orders; 4. For Resident #13, to implement a suicidal ideation care plan; 5. For Resident #142, to apply Geri Sleeves (protect the upper extremities from abrasions, bruises, snags and tears throughout the day. [...]

Inspectors wroteBased on observation, record review, and staff interviews, the facility failed to: 1. Ensure that the wound physician's recommendations were addressed and transcribed timely and accurately resulting in a delay of treatment for a skin injury on left foot/heel. Subsequently, the wound deteriorated to a Stage IV pressure injury and required an Intravenous (IV) antibiotics for treatment for one Resident (#124); and 2. Follow the physician's orders for prevention of a pressure ulcer for one Resident (#24), out of a total sample of 40 residents.

Inspectors wroteBased on observations, record review, and interview, the facility failed to ensure that the resident environment remained free of accident hazards. Specifically, the facility failed: 1. For Resident #141, to provide adequate supervision and assistance with ambulation resulting in a fall with skin tears and a laceration following a resident-to-resident altercation; 2. For Resident #13, to ensure fall mats were in place, as ordered by the Physician and indicated in his/her plan of care; 3. For Resident #23, to ensure seizure pads were placed on the bed's interior side rail to protect Resident #23 during a seizure; 4. For Resident #46, to ensure the facility policy for supervised smokers was adhered to and that interventions were put in place, following Resident #46's violating the smoking policy; 5. [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain a clean, sanitary, and homelike environment for residents residing on three of three units (Unit 1 A, Unit 2 ABC, and Unit 3). Specifically, the survey team observed: environmental cleanliness concerns in resident rooms, resident showers and hallways which included dirty wall surfaces, wall surfaces in disrepair, missing tiles, floors in need of washing, mouse droppings, dead mice, ants and black flies.

Inspectors wroteBased on observation, policy review, and interview, the facility failed to store and prepare food in accordance with professional standards for food service safety.

Inspectors wroteBased on observation, interview, and documentation review, the facility failed to implement an effective pest control program, as evidenced by sanitation concerns, mice sightings, and mice droppings on three of three units.

Inspectors wroteBased on observations, interviews, policy review, and record review, the facility failed to provide dignified experiences for four Residents (#140, #4, #108, #142), out of a sample of 40 residents. The facility also failed to provide a dignified dining experience on 2 out of 5 units. Specifically, the facility failed: 1. For Resident #140, to provide a dignified dining experience and dignified age-appropriate activities; 2. For Residents #4, #108, and #142, to ensure a catheter bag was covered for privacy; and 3. To address residents requiring assistance in a dignified manner on 2 out of 5 units.

Inspectors wroteBased on observations, record review, policy review, and interviews, the facility failed to ensure for two Residents (#24 and #112), who required dialysis received such services consistent with professional standards of practice and the comprehensive person-centered care plan, out of 40 sampled residents. Specifically, the facility failed: 1. For Resident #24, to ensure nursing implemented a physician's order and plan of care related to blood pressure checks; and 2. For Resident #112, to ensure nursing implemented a physician's order and plan of care related to blood pressure checks.

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide behavioral health services, for one Resident (# 95), out of a sample of 40 residents and 31 residents out of the facility census of 149 residents. Specifically, the facility failed to provide substance abuse counseling services for residents with a history of substance abuse.

Inspectors wroteBased on observations, records reviewed, policy review, and interviews, the facility failed to ensure it was free from a medication error rate of greater than 5% when 2 out of 4 nurses observed made 3 errors out of 30 opportunities resulting in a medication error rate of 10%. Those errors impacted 2 Residents (#25 and #64), out of 4 residents observed.

Inspectors wroteBased on interview and record review, the facility failed to take into consideration the dietary preferences of each resident. Specifically, the facility failed to accommodate residents' preferences for eating pork.

Inspectors wroteBased on interview and observation, the facility failed to ensure bedroom furniture and was in good working condition on one of three resident floors.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that one Resident (#24), out of a total sample of 40 residents, whose right to be informed of, and participate in his/her treatment plan, was honored, when his/her Health Care Agent, which was not invoked, signed Resident #24's advanced directive form, consent to treatment form, consent for wound services form, consent for bed rails form, and consent to psychotropic medication form.

Inspectors wroteNOT CORRECTED Based on observation, record review, policy review, and interview, the facility failed to ensure one Resident (#11) was assessed for the ability to self-administer medications, out of a total sample of 39 residents.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to implement their Abuse Investigation and Reporting policy for two Residents (#13 and #116) out of a total sample of 16 residents. Specifically, 1) Resident #13 reported to a Certified Nursing Assistant (CNA) that he/she was not provided with incontinence care over night and the CNA failed to promptly report the allegation to any staff, delaying the initiation of an investigation. 2) Resident #116 reported that staff had threatened him/her to the Assistant Director of Nursing (ADON) who had failed to report the allegation to the Administrator or initiate an investigation.

Inspectors wroteBased on Interview and policy review the facility failed to report an allegation of verbal abuse to the Department of Public Health within 2 hours of when the allegation was made for 1 Resident (#116) out of a total sample of 16 residents. Findings Include: Review of the facility policy titled Abuse Investigation and Reporting, dated as revised July 2017 indicated the following: -All reports of resident abuse, neglect, exploitation, misappropriation of resident property, mistreatment and/or injuries of unknown source (abuse) shall be promptly reported to local, state and federal agencies (as defined by current regulations) and thoroughly investigated by facility management. Resident #116 was admitted to the facility in July 2023 with diagnosis including anemia. [...]

Inspectors wroteBased on record review and interviews, the facility failed to update and revise care plans for two Residents (#19 and #142), out of a sample of 40 residents. Specifically, the facility failed: 1. For Resident #19, to update a behavior care plan after he/she was involved in two physical altercations with other residents; and 2. For Resident #142, to revise a care plan related to the size of an indwelling catheter.

Inspectors wroteBased on record review, policy review, and staff interviews, the facility failed to: 1. Implement the facility's policy to obtain a physician's order to administer COVID-19 vaccine for five Residents (#37, #19, #95, #84, and #5); 2. Ensure that a physician's telephone order for a medication was transcribed by the nurse according to professional standards of practice to include the name of the medication being ordered for two Residents (#124 and #45); and 3. Implement a physician's order for an ace wrap for one Resident (#13), out of a total sample of 40 residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a language manual to assist staff in communicating with one Resident (#140), out of a sample of 40 residents.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure Activity of Daily Living (ADL) assistance was provided to two dependent Residents (#13 and #23), out of a total sample of 40 residents. Specifically, the facility failed to provide assistance with bed mobility and eating.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to provide appropriate activities for one Resident (#140), out of a sample of 40 residents. Specifically, the facility failed to provide age-appropriate activities in the Resident's dominant language.

Inspectors wroteBased on record reviews, policy review, and interviews, the facility failed to: 1. Follow the recommendations of the eye doctor and schedule an appointment with a retina specialist for one Resident (#79); and 2. Develop and implement a plan of care for hearing and communication for one Resident (#142) who required a cochlear implant to maintain his/her hearing and communication, out of a total sample of 40 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper foot care for one Resident (#83), out of a total sample of 40 residents.

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed for one Resident (#108), out of a total sample of 40 residents, to maintain professional standards in the managing and care for urinary catheter devices. Specifically, the facility failed to maintain Resident #108's urinary catheter in a manner to prevent the possibility of infection.

Inspectors wroteBased on observation, record review, and interview, the facility failed to address significant weight changes for one Resident (#45), out of a total sample of 40 residents.

Inspectors wroteBased on observations, interviews, record review, and policy review, the facility failed to ensure enteral nutrition provided via a gastrostomy tube (G-tube- a feeding tube in abdomen used to provide nutrition) was provided in accordance of professional standards of practice and his/her physician's orders for one Resident (#112), out of a total sample of 40 residents. Specifically, Resident #112's physician ordered tube feed was ordered as continuous and did not account for a dialysis schedule and a meal schedule.

Inspectors wroteBased on observation, interview, and policy review, the facility failed to ensure medications once opened were dated as required on 2 of 4 sampled medication carts.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain an accurate medical record for four Residents (#13, #23, #4, and #112), out of a total sample of 40 residents. Specifically, 1. For Resident #13, the nurses documented in the Treatment Administration Record (TAR) that they had applied ace wraps to the Resident's legs, when they had not; 2. For Resident #23, the nurses documented in the TAR that the Resident was wearing a boot, when he/she was not; 3. For Resident #4, the facility failed to maintain an accurate record for a medication's dose as required; and 4. For Resident #112, the facility failed to ensure nursing maintained an accurate medical record related to the route of administration of a medication.

Inspectors wroteBased on observations, policy review, and interview, the facility failed to ensure staff disinfected reusable resident care equipment (a blood pressure cuff) between residents.

Inspectors wroteBased on interview and observation, the facility failed to ensure a smoke detector in a resident bedroom, located on the second floor, was free of obstruction and functioned properly.

Inspectors wroteBased on record review and interview, the facility failed to inform 3 out of 3 Residents, or their representatives, of potential liability for payment for non-covered services including estimated cost of services.

Inspectors wroteBased on observation and interview, the facility failed to post nurse staffing information, including the date, facility name, total number of hours worked for licensed and unlicensed staff, and the resident census number daily and in a prominent place, readily accessible to residents and visitors.