Millbrook Healthcare and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private meeting space for residents' monthly Resident Council Meeting for 10 of 10 confidential residents reviewed for Resident Council. The facility failed to provide a private space for residents who attended monthly Resident Council Meetings. This failure could place residents at risk of not being able to voice their concerns amongst each other due to a lack of privacy.

Inspectors wroteBased on interview and record review the facility failed to develop a person-centered, comprehensive care plan for each resident that included measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs for 6 (Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, Resident #8) of 6 residents reviewed for care plans.1 The facility failed to revise the person-centered care plan for six (Resident #12, Resident #9, Resident #43, Resident #4, Resident #59, Resident #8) of six residents addressed their interventions for Full Code or DNR on their Advanced Directives. 2. The facility failed to include the Advanced Directives for one (Resident #8) of one resident on the resident's Care Plan. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety.1. The facility failed to ensure food in the facility's dry storage and freezer areas were labeled and dated according to guidelines.2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas.3. The facility failed to ensure that expired items in the dry storage pantry and freezer areas were removed.4. The facility failed to ensure that dented cans were removed in the dry pantry area and were separated from the other canned food. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 6 residents (Resident #65 and #89) reviewed for infection control. The facility failed to ensure CNA C wore appropriate PPE and completed hand hygiene while providing incontinent care to Resident #65. The facility failed to ensure CNA E wore the appropriate PPE while transferring and providing incontinent care to Resident #89. The facility failed to ensure CNA F wore the appropriate PPE and completed hand hygiene while transferring and providing incontinent care to Resident #89. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable Dining Room for 10 of 10 confidential residents reviewed for safe, clean, and homelike environment.1. The facility failed to ensure the one chandelier in the Dining Room was clean and not dusty on 04/20/26, 04/21/26, and 04/22/26.2. The facility failed to ensure the one chandelier in the Dining Room had an operating bulb on 04/20/26, 04/21/26, and 04/22/26.3. The facility failed to ensure the four ceiling fans in the Dining Room were clean and not dusty on 04/20/26, 04/21/26, and 04/22/26.4. The facility failed to ensure that seven lights in the Dining Room were working properly on 04/20/26, 04/21/26, and 04/22/26. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations that involved abuse, neglect, exploitation or mistreatment, that included injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures. For 1 of 1 residents (Resident #56) reviewed for adequate supervision. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a Quarterly MDS Assessment for 1 of 6 residents (Resident #43) reviewed for Resident Assessments. The facility failed to ensure Resident #43's Quarterly MDS Assessment was completed within 90 days and included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care. This failure could place residents at risk of not having their individual care needs met, which could cause a decline in physical health, psychosocial health, and quality of care.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure residents were protected from accident hazards by not providing adequate supervision, not maintaining a hazard-free environment, resulted in actual or potential harm for 1of 1 residents (Resident#56) reviewed for safe positioning during incontinent care. The facility failed to implement effective safety interventions that would have prevented the resident from falling off the bed, did not provide the level of supervision necessary to prevent avoidable accidents. The facility had 1 of 1 resident who were left in unsafe situations, placing them at risk for falls and injury. These failures could place residents at risk of accidents and injury. Findings Include:Observation at 9:15am on 4/20/26 on initial tour observed Resident #56 in her room lying in the bed, not in a low position as indicated in the care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #65) of 3 residents reviewed with gastrostomy tubes (G-tubes) medical device inserted through the abdominal wall directly into the stomach to provide nutrition, fluids, and medication.) The facility failed to ensure CNA C did not manage Resident #65's feeding pump by turning the pump on and off during incontinent care. This failure could place residents with G- tubes at risk for complications, aspiration, and pneumonia.

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to protect and promote the right to a dignified existence for 1 (Resident#1) out of 3 residents reviewed, The facility failed to provide Resident#1 with a dignified lunch meal service, when the Medical Record Staff stood beside Resident#1 bed and leaned over Resident#1 to feed him on 10/24/25. This failure could result in resident not feeling respected and a decline in Quality of life.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #1) of 6 residents, reviewed for care plans. 1. The facility failed to follow the care plan and assess Resident #1 for pain at the start of each shift since 09/17/25. These failures could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being. Findings Included:Record review of Resident #1's face sheet, dated 09/25/25, reflected an [AGE] year-old female, who admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 3 Medication Carts (Medication Cart #1) reviewed for pharmacy services. 1. The facility failed to ensure Medication Cart #1 did not include discontinued medication, Lorazepam (Ativan) for Resident #1 after it was discontinued on 09/19/25. This failure could place residents at risk of receiving discontinued medication and possible adverse reactions. Findings Include:Record review of Resident #1's order summery on the electronic record, dated 09/25/25, reflected Lorazepam Oral Tablet 0.5 MG was discontinued. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to make sure that residents receive adequate respiratory care (including tracheostomy care and tracheal suctioning) for 3 of 5 Residents (Resident#1, Resident#2 and Resident#3), reviewed for infection control. The facility failed to ensure that Resident #1, Resident #2 and Resident #3's oxygen tubing and prefilled humidifier water bottles were changed and dated. The facility failed to ensure that Resident #3's oxygen tubing was bagged in a plastic bag and stored in a drawer. The failures had the potential to affect residents receiving oxygen therapy by increasing their risk of health -associated infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to complete a discharge summary that included a recapitulation of the resident's stay that included diagnoses, course of treatment, pertinent labs, a final summary of the resident's status and reconciliation of all pre-discharge medications with the resident's post-discharge medications for 1 of 5 residents (Resident #1) reviewed for closed records. The facility failed to ensure Resident #1 discharged the facility with a discharge summary that included an accurate and current description of the clinical status of the resident and sufficiently detailed, individualized care instructions to ensure that care is coordinated and the resident transitions safely from one setting to another. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had secure and confidential personal and medical records.for one (Residents #1) of 7 residents reviewed for confidentiality of records. The facility failed to ensure LVN A did not leave Residents #1's medication blister cards on top of an unattended Medication cart on the 100 hall, while she was in Resident #2's room with the door closed. This failure could place all residents at risk of having their medical information disclosed to visitors and other residents, causing embarrassment, frustration, decreased privacy and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering, and securing of medications for one resident (Resident #1) of 9 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received 5 of his routine doctor ordered medications between 7:00 am and 9:00 am on 05/07/25; subsequently they were not given to him until around 10:35 am. This failure placed residents at risk of not receiving the physician ordered medications on time, which could cause the residents to have a change of condition, resulting in a decreased quality of life and psychosocial well-being. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were in locked compartments for 1 (Residents #1) of 7 residents reviewed for medication storage. The facility failed to ensure LVN A did not leave Residents #1's medication blister cards on top of an unattended Medication cart on the 100 hall, while she was in Resident #2's room with the door closed. This failure could place all residents at risk of having their medications taken or consumed by other residents, which could cause a shortage of their medications or cause a change in their medical condition resulting in a decline in their health and psycho-social well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 of 8 (Resident #16, Resident #61, and Resident #27) residents reviewed for call lights. 1. The facility failed to ensure Resident #16 had a call light device appropriate to her limited use of her hands. She was provided a button type call light when she was unable to bend her fingers. 2. The facility failed to ensure Resident #61 had a call light device appropriate to her limited use of her hands. She was provided a button type call light device when both her hands were contracted into fists. 3. The facility failed to ensure Resident #27's call button was within reach while Resident #27 was in her bed.

Inspectors wroteBased on observations, interviews, 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 kitchens reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. These failures could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 02/09/25 beginning at 9:09 AM revealed unlabeled, undated, and uncovered food and beverage items: -3 trays of cups of dark liquid for a total of 18 cups of dark liquid; and -1 tray of cups of white liquid for a total of 11 cups of white liquid; and -3 trays with uncovered 12 slices of yellow cake on 3 trays for a total of 36 slices. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 6 (Resident #34, Resident #16 and Resident #36) residents reviewed for infection control. 1. CNA A failed to perform hand hygiene while performing incontinent care for Resident #34. 2. CNA A failed to perform hand hygiene while performing incontinent care for Resident #16. 3. CNA E failed to perform hand hygiene while performing incontinent care for Resident #36. These failures could place residents at risk for infection through cross contamination of pathogens.

Inspectors wroteBased on observations, interviews, and record review the facility failed to care for each resident in a manner that promoted maintenance and enhancement of their quality of life for one (Resident #36) of 8 residents reviewed for privacy and dignity. The facility failed to ensure Resident #36 was afforded visual privacy when receiving incontinent care; her coccyx was left exposed to passers-by in the hallway. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on interviews and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 4 residents (Resident #61 and Resident #34) reviewed for accuracy of assessments. The MDS Nurse failed to ensure Section C0200-C0500-Brief Interview for Mental Status (BIMS) was completed for Resident #61's Quarterly MDS assessment dated [DATE] and Resident #34's Quarterly MDS assessment dated [DATE] when she signed Section Z0400 indicating the sections had been completed. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Residents #41) reviewed for ADL care. The facility failed to ensure Resident #41's fingernails were kept trimmed. These failures could place the residents at risk of infections or injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 6 residents (Resident #1) reviewed for a clean and comfortable environment. The facility staff failed to remove a soiled brief from the floor in Resident #1's room. This failure could place residents at risk of living in an unsanitary environment leading to a diminished quality of life.

Inspectors wroteBased on record review and interview, the facility failed to employ a qualified social worker on a full-time basis, in that; The Social Service's Director was not supervised for a year which made her not a qualified social worker. Operation Manager revealed, she was aware of the requirement to have a social worker however, she did not realize the capacity exceeded the number for a licensed social worker. This failure could affect residents of the facility by placing them at increased risk of psychosocial decline and poor-quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of five residents (Resident #23) reviewed for infection control. MA A dropped medication on the medication cart and then picked the medications without gloves and administered to Resident #23 on 01/08/24. These failures could place residents at risk for contamination and infection.

Inspectors wroteBased on observation, interview, and record review, 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 transmission of communicable diseases for five (LVN A, Medical Records Staff B, OTA C, OTA D, and OT E) out of ten staff reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure LVN A wore an N95, or equivalent, mask over her mouth and nose at all times when in quarantined rooms with residents positive for COVID-19, including while suctioning a COVID-19 positive resident, according to the facility's policy. 2. [...]