Storybrook Care & Rehabilitation

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure the services provided or arranged by the facility met professional standards of quality for one (#7) of two residents out of nine sample residents. Specifically, the facility failed to ensure professional standards were followed when completing a peripherally inserted central catheter (PICC) line dressing for Resident #7.

Inspectors wroteBased on observations and interviews, the facility failed to ensure infection prevention and control programs (IPCP) were maintained and followed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections on one of two units. Specifically, the facility failed to ensure enhanced barrier precautions (EBP) were followed during a peripherally inserted central catheter (PICC) line dressing change.

Inspectors wroteBased on record review and interviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for two (#7 and #5) of seven residents reviewed for quality of care out of 10 sample residents. Specifically, the facility failed to:-Ensure Resident #7 and Resident #5 were assessed by a registered nurse (RN) following falls; and,-Ensure Resident #7, who was on anticoagulant medication (a class of medications that prevent or slow down blood clotting and can increase the risk of bleeding), received consistent and increased monitoring following a fall on 7/25/25 where the resident hit her head. The resident was transported to the emergency room three days post-fall, where she was diagnosed with a significant subdural hemorrhage (bleeding in the brain). [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#6) of four residents were kept free from physical abuse out of 10 sample residents. Specifically, the facility failed to ensure Resident #6 was kept free from physical abuse by Resident #3.

Inspectors wroteBased on record review, observations and interviews , the facility failed to provide a safe, clean, comfortable and homelike environment for the residents on two out of three hallways and one out of two dining rooms. Specifically, the facility failed to: -Ensure there were enough clean linens; and, -Maintain clean floors in the residents' rooms, hallways and main dining room.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure one (#5) of two residents reviewed for pressure injuries out of 19 sample residents received the necessary treatment and services to prevent the development of pressure injuries. Resident #5, who had a diagnosis of multiple sclerosis (an immune disease that disrupts nerve communication between the brain and the body) and generalized muscle weakness, was admitted to the facility on [DATE] for ongoing medical management and rehabilitation after a tibial and fibular fracture. Resident #5 was admitted to the facility with intact skin of the feet and heels. On 4/25/24 Resident #5 was assessed for risk of developing pressure injuries and was identified as moderate risk due to a history impaired mobility and bowel incontinence. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide a response, action and rationale to residents involved in group grievances. Specifically, the facility failed to: -Allow the resident council to meet without a staff member present; -Provide a private space for resident council; and, -Provide a response, action and rationale for food concerns.

Inspectors wroteBased on record review and interviews, the facility failed to provide ongoing communication to residents about their rights; and failed to inform the resident both orally and in writing in a language that the resident understands of his or her rights and all rules and regulations governing resident conduct and responsibilities during the stay in the facility. Specifically, the facility failed to provide ongoing communication and discussion to the resident's about their rights and responsibilities.

Inspectors wroteBased on observations, record review, and interviews the facility failed to provide a prompt effort to resolve grievances for one (#28) and the resident group out of 19 sample residents. Specifically, the facility failed to: -Follow through on grievances for lost/stolen items for and #28; and, -Ensure the residents had information on how to file a grievance.

Inspectors wroteBased on record review, and interviews the facility failed to assist residents in obtaining routine or emergency dental services, as needed for three (#10, #11 and #17) of five residents reviewed for dental services out of 19 sample residents reviewed. Specifically, the facility failed to replace Resident #10, Resident #11 and Resident #17's dentures in a timely manner.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to consistently serve food that was palatable, attractive, and at the appropriate temperature. Specifically, the facility failed to ensure resident food was palatable in taste, texture and appearance.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide food that accommodated resident preferences for three (#31, #6, #17) of five residents out of 19 sample residents. Specifically, the facility failed to offer food choices according to resident preferences for Resident #31, #Resident #6 and Resident #17.

Inspectors wroteBased on observations and interviews, the facility failed to store, prepare, distribute and serve food in a sanitary manner in the main kitchen. Specifically, the facility failed to: -Ensure food was labeled and dated appropriately; -Ensure food stored at least six inches above the floor; -Ensure to ensure the kitchen equipment was clean; and, -Ensure staff completed hand hygiene appropriately in the dining room.

Inspectors wroteBased on record reviews and interviews, the facility failed to incorporate the recommendations from the preadmission screening and resident review (PASRR) level II determination and evaluation report into the assessment, care planning and transition of care for one (#14) of one resident reviewed for PASRR out of 19 sample residents. Specifically, the facility failed to -Take steps to ensure services were provided as recommend in Resident #14's PASRR level II report; and, -Develop and implement a care plan to identify the PASRR level II recommendations for Resident #14.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public. Specifically, the facility failed to ensure the laundry room was free from environmental concerns.

Inspectors wroteBased on record review and interviews, the facility failed to ensure one (#30) of four residents reviewed for accidents out of 28 sample residents remained as free from accident hazards as possible. Resident #30, who was identified as a high fall risk, had numerous predisposing factors which included dementia, confusion, unsafe sleeping habits and poor safety awareness. The facility failed to develop, communicate and implement effective interventions to prevent the resident from falling on multiple occasions. Due to the facility's failures, the resident sustained a fracture to her right femur (hip) subsequent to a fall on 12/5/22, requiring hospital treatment.

Inspectors wroteBased on observations, record review and staff interviews, the facility failed to ensure one (#30) of six residents observed for nutrition out of 28 sample residents to maintain acceptable parameters of nutritional status. The facility failed to provide meal supplements per registered dietitian (RD) order and provide assistance during meal times. Resident #30, who was identified as having a significant weight loss, had numerous predisposing factors which included dementia, lack of appetite and confusion. She was admitted to the facility on [DATE] with a weight of 126 pounds. Due to the facility's failures, the resident sustained a weight loss of 10.4% in six months. Resident #30 sustained a weight loss of 10.4% (14 lbs) from admission on [DATE] through 4/1/23 which was considered significant. Observations revealed that the nutritional interventions were not consistently implemented.

Inspectors wroteBased on observations, record review and interviews the facility failed to provide effective pain management during wound care for one (#10) of three out of 28 sample residents. The facility failed to assess Resident #10 for pain after he developed two stage 3 pressure injuries. Nursing staff did not offer pain medication to the resident prior to the dressing changes. The resident experienced severe pain during dressing changes and refused the care due to the pain. In addition, nursing staff did not follow up with the physician regarding pain management and did not obtain an order for pain control prior to wound care and continued to provide dressing changes without offering pain medication. Resident #10 frequently refused care and his wounds deteriorated.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute, and serve food in a sanitary manner. Specifically, the facility failed to: -Ensure staff washed hands and changed single use gloves appropriately; and, -Ensure only food was stored in two out of two unit snack refrigerators, and food was sealed appropriately and discarded by the use by date.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an effective quality assurance program to identify and address facility compliance concerns was implemented, in order to facilitate improvement in the lives of nursing home residents, through continuous attention to quality of care, quality of life and resident safety. Specifically, the quality assurance performance improvement (QAPI) program committee failed to develop and implement effective action plans to address repeat deficiencies and ensure systemic and lasting improvement for quality of care issues.

Inspectors wroteBased on observations and staff interviews, the facility failed to maintain an infection control and prevention program designed to provide a sanitary environment to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility failed to: -Assess where Legionella and other opportunistic waterborne pathogens could grow and spread; and, -Implement measures to prevent the growth of Legionella and other opportunistic waterborne pathogens in building water systems according to nationally accepted standards.

Inspectors wroteBased on record review and interviews, the facility failed to implement a training system to ensure certified nurse aides (CNAs) had no less than 12 hours of education in the required areas each year. Specifically, the facility failed to: -Ensure five of five CNAs (#1, #2, #5, #6, and #7) were provided the required 12 hours of annual training based on their start date; and, -Ensure abuse prevention training was provided to CNAs #1 and #5.

Inspectors wroteBased on record review and interviews, the facility failed to ensure that residents were free of unnecessary psychotropic medications for one (#247) of one resident reviewed for psychotropic medications out of 16 sample residents. Specifically, the facility failed to: -Ensure the staff monitored Resident #247 for side effects of eight psychotropic medications including sedation and hypotension; -Ensure staff accurately monitored and tracked Resident #247 for target behaviors and hours of sleep for four antidepressant medications, with one being used for insomnia, one for depression, one for anxiety and one for hallucinations; two antipsychotic medications for dementia with behavioral disturbance; and, two anti anxiety medications for generalized anxiety; -Ensure consents were signed by Resident #247's representative prior to psychotropic medication administration; [...]

Inspectors wroteBased on record observations, record review and interviews, the facility failed to residents received food and fluids prepared in a form designed to meet the residents' needs. Specifically, the facility failed to ensure residents had food prepared according to their diet orders of mechanical dysphagia level 2 as indicated on their meal tray cards.

Inspectors wroteBased on observations, record review and interviews, the facility failed to implement their policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption for three residents out of 28 sample residents. Specifically, the facility failed to: -Ensure resident refrigerators maintained appropriate temperatures for refrigerated food storage; and, -Ensure sanitary food storage for Resident #12's refrigerator in her room.

Inspectors wroteBased on observation and interviews, the facility failed to provide a clean, safe, homelike environment for the residents in one of four units. Specifically, the facility failed to store medical equipment in a specified area away from the resident's rooms and high traffic areas.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide necessary assistance with activities of daily living (ADLs) for one (#12) out of 28 sample residents to maintain personal hygiene. Specifically, the facility failed to provide assistance with showers as scheduled to maintain personal hygiene and grooming for Resident #12, who was dependent for care.

Inspectors wroteBased on record review, resident interview and staff interviews, the facility failed to ensure proper treatment and assistive devices to maintain vision abilities for one (#7) of three residents reviewed for visual problems out of 28 sample residents. Specifically, the facility failed to provide assistance with hearing aids to Resident #7 and ensure hearing aids were stored safely.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure assessment, inspection and maintenance of a bed cane (fixed bed rail assistive device) was completed for one (#12) resident using bed cane (type of bed rail) for positioning out of 28 sample residents. Specifically, for Resident #12, the facility failed to: -Assess the resident for risk of entrapment prior to installing or using a bed cane/bed rail; and, -Check bed rail/bed cane regularly according to manufacturer's instructions for ongoing maintenance to make sure device was still installed correctly as rails may shift or loosen over time.

Inspectors wroteBased on observations and interviews the facility failed to ensure residents had the right to a safe, clean and comfortable homelike environment for six out of 16 resident rooms. Specifically, the facility did not facilitate the necessary housekeeping and maintenance services to maintain the resident rooms to include room [ROOM NUMBER], #117, #118, #120, #128, and #130 in a sanitary and comfortable manner.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide assistance with activities of daily living (ADLs) to ensure the highest practicable quality of life and care, for five (#11, #23, #32, #3, and #10) of six residents reviewed out of 25 sample residents. Specifically, the facility failed to: -Provide regular and consistent showers according to preferences and plan of care for Residents #11, #23, #32, #3, and #10 who needed assistance with ADLs.

Inspectors wroteBased on observations, record review and interviews, the facility failed to provide an ongoing program to support residents in their choice activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the memory care unit for four (#1, #27, # 31and #38) of six out of 25 sample residents. Specifically, the facility failed to invite and offer activities of choice to Residents #1, #27,# 31 and #38 in the memory care unit.

Inspectors wroteBased on observations, record review and interviews, the facility failed to ensure consents were obtained, behaviors were tracked/monitored and pharmacist recommendations were followed for the use of psychotropic medications for four (#2, #3, #15 and #31) of five out of 25 sample residents. Specifically, the facility failed to ensure: -Resident #2: the resident or their representative gave consent for the use of Sertraline (antidepressant) prior to its administration. The facility also did not initiate a methodology of tracking/monitoring the resident's behaviors for the use of this medication. The facility failed to have a specific care plan for the Sertraline medication. -Resident #3: [...]

Inspectors wroteBased on record review, observations and interviews the facility failed to develop and implement a comprehensive centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for one (#30) of five out of 25 sample residents. Specifically, the facility did not ensure care plans and interventions were developed for the resident's use of anticoagulant, antidiabetic and hypertensive medications for Resident #30.