Mill Brook Rehabilitation and Healthcare Center

Inspectors wroteBased on interviews and record review, the facility failed to ensure monthly Medication Regimen Review (MRR) recommendations made by the pharmacy consultant were addressed timely and maintained as part of the permanent medical record for two Residents (#16 and #5), out of a total sample of 27 residents. Specifically, the facility failed:1. For Resident #16, to ensure the April 2025 and May 2025 consultant pharmacist recommendations were maintained as part of the permanent medical record and acted upon timely to assess the need for Meclizine (an anticholinergic medication used to treat nausea, vomiting and dizziness) and to obtain an A1c (blood test that measures an average blood sugar level over a period of two to three months); and2. [...]

Inspectors wroteBased on observation and interview, 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 ensure the main kitchen walk-in refrigerator was maintained in a sanitary and safe condition.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents were provided care in accordance with professional standards of practice for two Residents (#13 and #86), out of a total sample of 27 residents. Specifically, the facility failed:1. For Resident #13, to ensure physician's orders were complete for the management of a continuous glucose monitoring sensor and included orders to remove and change the device every 14 days; and2. For Resident #86, to complete weekly skin check documentation per physician's orders.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#46), out of 27 sampled residents, and one Resident (#159), out of three closed records, received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices to achieve their highest practicable physical, mental, and psychosocial well-being. Specifically, the facility failed:1. For Resident #46, to ensure the Wound Physician's recommendations were addressed and implemented timely for a skin tear; and2. For Resident #159, to: a. Accurately transcribe the physician's order to send Resident #159 to the emergency room for evaluation, resulting in a minimum of a nine-hour delay (6/30/25 5:00 P.M. to 7/1/25 2:00 A.M.) in transferring the Resident to the hospital, and b. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#46), out of a total sample of 27 residents, received the necessary care and treatment to prevent and promote healing of pressure injuries. Specifically, the facility failed to ensure Wound Physician recommendations were addressed and implemented timely.

Inspectors wroteBased on observations, interviews and policy review, the facility failed to store, distribute, and serve food under sanitary conditions to promote safe food handling. Specifically, the facility failed to: 1. Ensure hair was restrained when preparing food; and 2. Ensure staff practiced proper hand hygiene to prevent cross contamination (transfer of pathogens from one surface to another). In addition, to ensure the use of gloves was limited to a single use task; and 3. Ensure staff monitored cooked food temperatures being held for service to residents.

Inspectors wroteBased on a resident group meeting, staff interviews, and document review, the facility failed to ensure grievances and concerns from Resident Council were acted upon and promptly resolved from 12/6/23 through 7/8/24 as required.

Inspectors wroteBased on record review, interview, and policy review, the facility failed to follow professional standards of practice for two Residents (#343 and #104), out of a total sample of 26 residents. Specifically, the facility failed: 1. For Resident #343, to monitor the Resident's left upper extremity midline catheter insertion site for signs/symptoms of infection and/or infiltration every shift in accordance with the physician's order; and 2. For Resident #104, to ensure the physician conducted an accurate assessment of the Resident upon admission, per accepted standards of clinical practice, resulting in an inaccurate diagnosis of schizophrenia to be added to the Resident's list of active diagnoses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff stored all drugs and biologicals used in the facility in accordance with currently accepted professional principles. Specifically, the facility failed to: 1. Ensure the treatment cart on Cookside Unit was locked when not in direct supervision of the licensed nurse; and 2. Ensure safe storage of medications and biologicals according to current standards of practice in 2 of 3 observed medication carts.

Inspectors wroteBased on observations, interviews, and menu review, the facility failed to ensure that menus posted were followed.

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

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure that for one Resident (#43), out of a total sample of 26 residents, the nurse provided the Resident privacy while administering medication, specifically an insulin injection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure activity of daily living (ADL) care was provided to maintain good personal grooming for one Resident (#115), in a total sample of 26 residents. Specifically, the facility failed to ensure nail care was performed for Resident #115.

Inspectors wroteBased on observation, interview and record review, the facility failed to arrange for an audiology appointment for one Resident (#115), out of 26 sampled residents, to address the Resident's hearing loss.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the Physician documented a clinical rationale for disagreeing with the consultant pharmacist's identified and reported irregularity (order for an antipsychotic medication without supporting diagnosis for usage) for one Resident (#40), out of a total sample of 26 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure one Resident (#40), out of a total sample of 26 residents, was free from unnecessary psychotropic medication. Specifically, for Resident #40, the facility failed to ensure an antipsychotic was given to treat a specific condition.

Inspectors wroteBased on record review and interviews, the facility failed to maintain accurate medical records in accordance with accepted professional standards for two Residents (#99 and #115), in a sample of 26 residents. Specifically, the facility failed to ensure the electronic medical record orders accurately reflected the advanced directives indicated on the Massachusetts Medical Orders for Life-Sustaining Treatment (MOLST) for Resident #99 and Resident #115.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his/her daily nutritional and special dietary needs, taking into consideration the preferences of each resident. Specifically, for two Residents (#7 and #49), the facility failed to ensure the Residents' food preferences were met.

Inspectors wroteBased records reviewed and interviews, for one of four sampled staff members personnel files (Nurse #1), the Facility failed to ensure they consistently implemented measures related to abuse prevention and hiring practices, when training on the Facility Abuse Policy was not conducted on hire at orientation for Nurse #1, in accordance with the Facility Policy.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure a physician was notified of changes for one Resident (#45) in order to alter the treatment, in a total sample of 21 residents. Specifically, the facility failed to notify the physician of a recommendation to change the treatment for a wound on the right great toe.

Inspectors wroteNOT CORRECTED Based on observations, interviews, and record review, the facility failed to ensure one Resident (#91), out of a total sample of 17 residents, received care and treatment to prevent and to promote healing of a pressure injury. Specifically, the facility failed to implement treatments as ordered, notify the physician, and reassess worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to an unstageable pressure area to the Resident's coccyx.

Inspectors wroteBased on policy review, record review, and interviews, the facility failed to maintain an environment free of accident hazards for one Resident (#53), out of a sample of 21 residents. Specifically, the facility failed to ensure an adverse medication event, which necessitated the Resident to be emergently transferred to the hospital for evaluation and resulted in psychosocial distress to the Resident, was investigated and reported according to facility policy.

Inspectors wroteBased on observations and interviews, the facility failed to store, distribute, and serve food under sanitary conditions to promote safe food handling.

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 corporate operations for contracts failed to re-evaluate the use of the preferred vendors of staffing agencies.

Inspectors wroteBased on interview and document review, the Medical Director failed to attend the last two quarterly Quality Assessment and Performance Improvement (QAPI) meetings as required.

Inspectors wroteBased on observation, interview, policy review, and review of staff and resident testing logs, and resident records, the facility failed to ensure outbreak testing for COVID-19 was implemented for staff and residents following as per facility policy. Specifically, the facility failed to: 1. Ensure staff COVID-19 weekly testing was accurately documented and completed for all staff until the facility went 14 days without a new case, and 2. Ensure 4 out of 6 residents reviewed were tested per the recommendations of Department of Public Health (DPH) Rapid response team and documented in medical record during outbreak testing.

Inspectors wroteBased on resident and staff interviews, policy review, and document review, the facility failed to ensure grievances and concerns from the Resident Council were acted upon timely and resolved to the residents' satisfaction.

Inspectors wroteBased on policy review, interview, document review, and record review, the facility failed to implement the facility's grievance policy for 9 of 9 grievances reviewed and for two Residents (#6 and #85), from a sample of 21 residents. Specifically, the facility failed to: 1. For 5 of 9 grievances reviewed, notify the Administrator as required if a grievance/complaint involves a potential violation of a resident right or allegation of neglect or abuse and for 9 of 9 grievances reviewed, investigate and resolve grievances according to facility policy; 2. For Resident #6, follow up on a grievance of a broken item for over five months; and 3. For Resident #85, to research and follow up on a grievance of being left on a bed pan for over an hour.

Inspectors wrote4. Resident #43 was admitted to the facility in February 2022 with diagnoses including insulin dependent diabetes mellitus. Review of the February 2023 Physician's Orders indicated the following: -Insulin Lispro (short acting)- Sliding scale: If Blood Sugar is: 150-199 = (1 Unit); 200-249 = (2 Units); 250-299 = (3 units); 300-349 = (4 units); 350-399 = (6 units); 400--449= (8 Units); >450 (10 Units) and call physician Before meals and at Bedtime (6:30 A.M., 11:30 A.M., 4:30 P.M., and 8:00 P.M.). -Insulin Glargine (long acting insulin) solution 100 unit/milliliter (ml) amt.-16 units, subcutaneous, once a day at 6:00 A.M. Record review indicated that the Resident was being administered a dose of insulin every day at 6:00 A.M. and could potentially be receiving doses in addition to the daily insulin depending on the blood sugar results. [...]

Inspectors wroteBased on observation, record review, policy review, and interview, the facility failed to ensure that staff provided care and services according to accepted standards of clinical practice for seven Residents (#101, #10, #43, #90, #63, #45, and #91), out of a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #101, to ensure laboratory work was completed, as ordered by the physician; 2. For Resident #10, to: a. obtain a physician's order with instructions/ranges for physician notification of a low or a high capillary blood glucose (CBG), and b. apply TED stockings (elastic stockings) as ordered and accurately document as administered; 3. For Resident #43, to: a. have a physician's order to perform CBG's/Finger Stick Blood Sugars (FSBS) to correlate with the administration of the sliding scale insulin, b. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the Physician evaluated the residents' conditions and total program of care for four Residents (#45, #53, #91 and #63), out of a total sample of 21 residents. Specifically, the physician failed to review the following total programs of care: 1. For Resident #45, for the development of a diabetic wound; 2. For Resident #53, for the re-admission status of Resident #53 after emergency room evaluation following an adverse medication event; 3. For Resident #91, for the re-admission status of Resident #91with dehydration and an indwelling Foley catheter (flexible tube inserted through the urethra and into the bladder to drain urine); and 4. For Resident #63, for the wound of the left heel.

Inspectors wroteBased on observation, interview, and schedule review, the facility failed to ensure there was sufficient staff available to provide nursing services and care required to meet the residents' needs resulting in long wait times for call light response.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to have the attending physician review and sign the identified pharmacological recommendations so that action could be taken to address them for one Resident (#38), in a sample of five residents reviewed for unnecessary medications.

Inspectors wroteBased in record review, policy review and interview, the facility failed to ensure that the resident's drug regimen was free from unnecessary drugs without adequate monitoring in place for six Residents (#45, #91 #10, #34, #43 and #90) from a total sample of 21 residents. Specifically, the facility failed to ensure that: 1. Residents #45, #91, #10, and #34 had been monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-coagulant; and 2. Residents #43 and #90 had been monitored for signs/symptoms of adverse consequences (i.e., side effects) and the effectiveness of an anti-diabetic agent.

Inspectors wroteBased on interview, policy review, and record review, the facility failed to ensure four Residents (#53, #91, #38, and #86) were free from unnecessary psychotropic medications, in a total sample of 21 residents. Specifically, the facility failed to ensure: 1. For Resident #53, resident specific, targeted behaviors were identified and monitored for the use of the psychotropic medications Sertraline (antidepressant) and Quetiapine (antipsychotic); 2. For Resident #91: a. resident specific, targeted behaviors were identified and monitored for the use of the psychotropic medications Cymbalta (antidepressant) and Zyprexa (antipsychotic), and b. an as needed (PRN) psychotropic medication included a duration for use and was reviewed by the physician with a documented rationale for continued use; 3. [...]

Inspectors wroteBased on observation, test tray results, and interview, the facility failed to ensure that staff served food that is palatable and at an appetizing temperature on 2 out of 3 units, for 2 out of 2 test trays conducted.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an appropriate seating device to support the Resident's right lower leg with a long leg brace for comfort and proper support for one Resident #308, out of a total sample size of 21 residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure wound management was conducted for two Residents (#38 and #86), in a total sample of 21 residents. Specifically, the facility failed: 1. For Resident #38, to ensure wound recommendations, approved by the physician, were implemented; and 2. For Resident #86: a. to ensure skin evaluations were performed weekly per physician's orders, and staff documented and monitored the below knee surgical incision site for early signs of infection, b. to perform dressing changes to the right foot, per physician's orders, and c. to maintain the cleanliness of the stump shrinker (sock worn to reduce, prevent and control edema) being worn over the left below knee amputation that was currently being treated for an infection.

Inspectors wroteBased on record review, policy review, and interview, the facility failed to provide the necessary respiratory care and services in accordance with professional standards of practice for one Resident (#2A), out of a total sample of 17 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, through ongoing communication and collaboration with the dialysis facility for one of one Resident (#10), receiving dialysis. Specifically, the facility failed to ensure the hemodialysis communication book was completed by facility staff pre-treatment and dialysis staff post-treatment.

Inspectors wroteBased on record review, document review, and interview, the facility failed to ensure that services were coordinated with the Hospice provider to implement the resident's plan of care as required in the provider contract agreement for one Resident (#98), from of a total sample of 21 residents. Specifically, the facility failed to ensure: a. a physician's order for the provision of Hospice care was obtained, and b. an integrated care plan was developed to accurately reflect services provided by both the Hospice provider and facility staff.

Inspectors wroteBased on record review and interview, the facility failed to ensure its staff accurately coded Minimum Data Set (MDS) assessments for four Residents (#53, #105, #63, and #101), out of a sample of 21 residents. Specifically, the facility failed to ensure: 1. For Resident #53, the Resident's diagnosis of diabetes mellitus was coded on the most recent assessment; 2. For Resident #105, discharge status was accurately coded; 3. For Resident #63, pressure ulcer was coded; and 4. For Resident #101, anticoagulation medication was coded.

Inspectors wroteBased on record review and interview, the facility failed to ensure that individualized, comprehensive care plans were reviewed and revised for two Residents (#39, #45), out of 21 sampled residents. Specifically, the facility failed to ensure: 1. For Resident #39, the care plan was revised to reflect a. resolution of bruising; and b. resolution of a stage 2 pressure area to his/her heel; and 2. For Resident #45, the care plan was revised to reflect the resolution of a diabetic ulcer to the right toe.