Thatcher Brook Rehabilitation & Care Center

Inspectors wroteBased on observation, interview, and record review it was determined, for 4 of 26 sampled residents, that the facility did not ensure that all drugs and biologicals were stored and labeled in accordance with accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date when applicable. Specifically, an insulin pen and a vial of insulin were not dated with an open date or expiration date. Additionally, medications were found in the sink in the medication room and a medication cart was left unlocked and unattended. Resident identifiers: 2, 21, 24, and 31.

Inspectors wroteBased on observation and interview, for 8 of 26 sampled residents, the facility did not provide food prepared by methods that conserve flavor and appearance or provide food and drink that was palatable, attractive, and at an appetizing temperature. Specifically, residents complained of food quality, the test tray did not appear appetizing and was not palatable.

Inspectors wroteBased on observation and interview, the facility did not store, prepare, distribute and serve food in accordance with professional standards for food service safety. Specifically, food items in the walk-in freezer and walk-in refrigerator were open to the air, the stove was not clean, the top of the oven was not clean, meat in the refrigerator was not labeled and a large bucket of pickles did not have an open date.

Inspectors wroteBased on observation, interview and record review it was determined, for 3 out of 26 sampled residents, that the facility did not 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. Specifically, observations were made of staff not donning Personal Protective Equipment (PPE) for residents on Enhanced Barrier Precautions (EBP), staff were observed not performing hand hygiene during dressing changes and cross contamination was observed during a dressing change with improper cleaning of the insertion site. Resident identifiers: 3, 15, and 18.

Inspectors wroteBased on observation and interview it was determined that for 1 of 26 sampled residents, that the facility did not treat each resident with respect and dignity and care for each resident in a manner and environment that promoted maintenance or enhancement of their quality of life, recognizing each resident's individuality. Specifically, an observation was made of staff standing while feeding a resident. Resident identifier: 35.

Inspectors wroteBased on interview and record review, for 1 of 26 sampled residents, the facility did not notify the resident or the resident's representative of the transfer or discharge, and the reason, in writing at the time of discharge. Additionally, the resident was not informed of the bed hold policy in writing with specification of the duration during which the resident was permitted to return and resume residence in the facility. Specifically, a resident who was discharged to the hospital was not provided discharge documentation. Resident identifier: 2Findings included: Resident 2 was admitted to the facility on [DATE] with diagnoses that included fracture of left tibia and fibula, respiratory failure with hypoxia, neuralgia, and neuritis, type 2 diabetes, anxiety disorder, epilepsy and morbid obesity. Resident 2's medical records were reviewed between 7/21/25 - 7/23/25. [...]

Inspectors wroteBased on observation and interview it was determined, for 2 out 26 sampled residents, that the facility did not provide an ongoing program to support residents in their choice of activities both facility-sponsored group and individual activities and independent activities designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community based on the comprehensive assessment and care plan. Specifically, there were no activities besides bingo three times a week and residents complained of not enough activities. Resident identifiers: 25 and 30.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 26 sampled residents, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision to prevent accidents. Specifically, a resident did not have new interventions implemented after falls. Resident identifier: 30.

Inspectors wroteBased on interview, and record review, it was determined for 1 of 26 sampled residents, the facility did not ensure that residents who require dialysis receive such services consistent with professional standards of practice. Specifically, the facility was not providing immediate monitoring and documentation of resident's vital signs and the status of a resident's dialysis fistula upon return from the dialysis treatment center. Resident identifiers: 4.

Inspectors wroteBased on observation, interview and record review, for 1 of 26 sampled residents, the facility did not have menus that met the nutrition needs of residents in accordance with established nutrition guidelines, and did not follow the menu for a resident with special dietary needs. Specifically, a resident who required a specialized diet was not given adequate substitutions for listed menu items. Resident identifier: 7.

Inspectors wroteBased on observation, interview and record review it was determined, for 1 of 26 residents sampled, that the facility did not ensure that each resident received food that accommodated the resident allergies, intolerances, and preferences. Specifically, a resident had a food preference dislike of pork and received pork products as meal items. Resident identifier: 15.

Inspectors wroteBased on interview and record review it was determined, for 1 of 26 sampled residents, that the facility did not ensure that the antibiotic stewardship program included antibiotic use protocols and a system to monitor antibiotic use. Specifically, a resident was prescribed an antibiotic prophylactically for the treatment of chronic urinary tract infections (UTI) without any documented evidence that the resident was showing signs and symptoms of a current infection. Resident identifier: 30.

Inspectors wroteBased on interview and record review it was determined, for 1 of 5 residents sampled, that the facility did not offer a pneumococcal immunization, unless the immunization was medically contraindicated or the resident had already been immunized. Specifically, the facility did not have evidence to demonstrate that the resident was administered, offered, or declined the second dose of the pneumococcal immunization series. Resident identifier: 29.

Inspectors wroteBased on observation, interview and record review it was determined, for 4 of 16 resident's sampled, that the facility did not 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, including COVID-19. [...]

Inspectors wroteBased on interview and record review, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee developed and implemented appropriate plans of correction to correct identified quality deficiencies. Specifically, the facility was found to be in non-compliance for two of the same deficiencies identified on an infection control survey as well as the previous recertification survey. Resident identifiers 5, 11, 120, and 223.

Inspectors wroteBased on interview and record review it was determined that the facility did not ensure that the infection prevention and control program (IPCP) included a system to monitor antibiotic use. Specifically, the facility IPCP had not been tracking the facility infections and antibiotic use since February 2022.

Inspectors wroteBased on interview and record review it was determined, for 1 out of 16 sampled residents, that the facility did not consult with the resident's physician and notify, when there was a need to alter the resident's treatment. Specifically, medications were not administered due to not being available from the pharmacy. Resident identifier 12.

Inspectors wroteBased on observation, interview, and record review it was determined, for 1 of 16 sample residents, that the facility did not ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice. Specifically, facility staff were not cleaning the resident's Continuous Positive Airway Pressure (CPAP) machine, mask and tubing. Resident identifier: 5.

Inspectors wroteBased on interview and record review it was determined, for 1 of 16 sampled residents, that the facility did not provide pharmaceutical services to meet the needs of each resident. Specifically, medications were not administered due to being unavailable from the pharmacy. Resident identifier 12.

Inspectors wroteBased on interview and record review it was determine, for 1 of 16 sampled residents, that the facility did not obtain radiology services only when ordered by a physician. Specifically, x-rays were obtained without a physician order. Resident identifier 120.

Inspectors wroteBased on interview and record review it was determined, for 2 of 16 sample residents, that the facility did not maintain medical records on each resident that were complete and accurately documented. Specifically, documentation regarding a resident's Physician Orders for Life Sustaining Treatment (POLST) was not in the medical record and a resident's immunization history was not in the medical record. Resident identifiers: 19 and 120.

Inspectors wroteBased on interview and record review it was determined, for 2 of 8 sampled facility staff members, that the facility did not ensure that routine testing of facility staff for COVID-19 was completed based on the parameters set forth by the Secretary. Specifically, routine testing of not up to date vaccinated staff members, based on the county transmission rate, was not completed. Staff identifiers: Licensed Practical Nurse (LPN) 2 and Dietary Staff Member (DSM) 1.

Inspectors wroteBased on interviews and record review, it was determined, the facility did not ensure the resident's medical record included documentation that indicates, at a minimum, the following: that the resident or resident representative was provided education regarding the benefits and potential risks associated with Coronavirus Disease - 2019 (COVID-19) vaccine; each dose of COVID-19 vaccine administered to the resident; or if the resident did not receive the COVID-19 vaccine due to medical contraindications or refusal. Specifically, for 1 of the 5 sampled residents, the facility did not keep documentation within the residents' medical record regarding the residents' COVID-19 vaccination refusal or education of the benefits and potential risks associated with COVID-19 vaccination. Resident identifiers: 122.