Below average — CMS composite of the measures below.
A standard survey is most likely before around October 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Brookside Rehabilitation And Healthcare Center during CMS and state inspections, most recent first.
A resident with severe dementia and an invoked HCP had a physician order and a court decree affirming the HCP, but the facility failed to maintain a physical copy of the HCP form in the medical record identifying the Health Care Agent. The court decree on file did not name the agent, and the DSS, DON, and Administrator all reported they were unable to locate the HCP, despite facility policy requiring that documentation of the resident representative’s authority be obtained and kept in the record.
The facility did not complete scheduled deep-cleaning in 12 out of 15 observed rooms, resulting in thick dust accumulation on high surfaces such as overbed light fixtures and televisions. A resident's representative raised concerns about room cleanliness, and staff confirmed that terminal cleaning had not been performed as scheduled. Facility leadership acknowledged there was no monitoring process in place for environmental cleanliness, and the Administrator was unaware of the missed cleanings.
Two residents were not protected from unnecessary psychotropic medication use. One received PRN antipsychotic medication without a required 14-day limit or physician documentation for continued use, while another was maintained on the same antidepressant dosages for over a year without any attempt at gradual dose reduction (GDR) or documentation that a GDR was contraindicated. The DON confirmed these deficiencies and the lack of supporting documentation.
Staff did not follow physician orders for a resident's indwelling urinary catheter, resulting in the use of an incorrect catheter size and failure to perform a scheduled catheter change as documented. The DON confirmed the catheter in use did not match the current orders and the required change had not been completed.
A deficiency was cited for not providing enough food and fluids to maintain a resident's health, as required. The report indicates that the facility did not meet the necessary standards for nutrition and hydration, but does not include further details about the circumstances or the resident's condition.
A resident with multiple respiratory conditions was observed receiving oxygen therapy at 4 LPM via nasal cannula without a physician order in place. Nursing staff and the DON confirmed that oxygen was being administered without the required order, contrary to facility policy and professional standards.
A resident who required dialysis did not receive safe and appropriate dialysis care and services as needed. The facility did not ensure that dialysis care was provided according to the resident's requirements.
Surveyors found that both kitchenettes had refrigerators containing expired, unlabeled, and undated food items, as well as spilled food and debris. There was confusion among the Dietary, Housekeeping, and Nursing departments regarding responsibility for cleaning and monitoring these refrigerators, resulting in a lack of scheduled maintenance and oversight.
Surveyors identified that two residents did not have accurate clinical records: one resident's PRN Tramadol administration and its effectiveness were not documented on the MAR, despite the medication being given, and another resident's Foley catheter care was inaccurately recorded, with staff signing off on catheter changes that were not performed and discrepancies in catheter size. These actions were not in accordance with facility policy and professional standards.
A nurse failed to disinfect a multi-use glucometer with a bleach-based product after checking a resident's blood sugar, instead using Lysol wipes not validated for this purpose. The glucometer was then returned to the medication cart for use on other residents, contrary to both facility policy and manufacturer guidelines. The nurse was unaware of the correct procedure, and facility policies had not been updated to reflect the requirements for the newer glucometer model.
The facility did not have policies and procedures in place to ensure residents were assessed for, offered, or administered flu and pneumonia vaccinations, nor was there documentation of vaccine administration or refusal.
The facility failed to accurately complete MDS assessments for three residents, including not coding diuretic use for a resident with heart failure, misclassifying antiplatelet medications as anticoagulants for another, omitting tobacco use for a resident who smoked, and not documenting a therapeutic diet for a resident on dialysis, despite clear evidence in medical records and staff interviews.
The facility failed to conduct interdisciplinary care plan meetings and involve residents or their representatives in the care planning process for four residents. Documentation was missing for care plan meetings following MDS assessments, and residents reported not being aware of or invited to such meetings. The Administrator confirmed the absence of evidence for these meetings.
The facility failed to honor a resident's meal portion request made by the Resident Representative. Despite multiple requests for double meal portions due to the resident's constant hunger, the facility did not evaluate or implement the request. The Food Service Director and Dietitian were unaware of the request, resulting in the resident continuing to receive single meal portions.
The facility failed to develop and implement a care plan for a resident who exhibited behaviors of eating nonfood items and topical medications. Despite multiple documented incidents and staff awareness of the behavior, no care plan was created to address these issues, leaving staff without documented interventions to manage the resident's behavior.
The facility failed to provide adequate nutrition care and monitoring for a resident receiving artificial nutrition via a Jejunostomy tube. The staff did not consistently implement, monitor, and evaluate weekly weights, nor did they reassess the resident's refusal to be weighed. Additionally, the staff failed to adjust tube feed recommendations and offer alternative options when the resident could not tolerate increased tube feeds, leading to significant weight loss and unmet nutritional goals.
The facility failed to provide appropriate respiratory care for two residents by not monitoring and maintaining respiratory equipment, lacking physician orders for oxygen use, and not changing oxygen and nebulizer tubing as required. Observations revealed unsanitary conditions and improper storage of respiratory equipment.
A facility failed to monitor a resident's AV fistula for signs of patency and infection, leading to significant bruising and swelling that required emergency medical intervention and surgery. The resident, who had ESRD and received hemodialysis three times a week, experienced issues due to the lack of proper monitoring and documentation as per facility policy.
A resident with Dementia ingested [NAME] Lotion and house barrier cream due to improper medication storage, resulting in hospitalization and monitoring for gastrointestinal upset. The facility failed to adhere to its medication storage policy, and no staff education was completed following the incidents.
The facility failed to update a resident's Physician's orders to match the MOLST, resulting in a discrepancy between the DNR status indicated in the MOLST and the Full Code status in the EMR. The resident had Dementia with Behavioral Disturbance, and the error was identified during an interview with a nurse.
The facility failed to implement Enhanced Barrier Precautions (EBP) for a resident with a tracheostomy and gastrostomy tube. Staff did not wear appropriate PPE, and there was no EBP signage outside the resident's room, despite being aware of the requirements.
The facility failed to accurately code the MDS for two residents. One resident's MDS did not reflect a Stage Four pressure ulcer present on re-admission, and another resident's MDS did not indicate the use of IV hydration despite receiving it. The MDS Nurse confirmed the coding errors.
Failure to Maintain Health Care Proxy Documentation in Medical Record
Penalty
Summary
The facility failed to maintain a complete and accurate medical record for a resident with an invoked Health Care Proxy (HCP) that had been affirmed by the court. The facility’s policy on resident representatives required that documentation designating the representative’s authority be obtained by the director of nursing or designee and maintained in the record. The resident, admitted with diagnoses including unspecified severe dementia with mood disturbance, hypertension, and osteoarthritis of the knees, had a Minimum Data Set assessment indicating moderately impaired cognitive function and an invoked HCP. A physician’s order directed that the resident’s HCP be invoked, and the medical record contained a court decree affirming the HCP. Despite this, review of the resident’s medical record showed there was no physical copy of the HCP form identifying the Health Care Agent (HCA). The court decree in the record did not list the name of the HCA, and there was no other documentation in the chart that specified who the HCA was. During interviews, the Director of Social Services stated that the resident had been admitted before her employment and that she was unable to locate the HCP, acknowledging it should have been in the medical record. The Director of Nursing and the Administrator also reported they could not locate the HCP and confirmed that a copy should have been available in the record.
Failure to Maintain Clean and Homelike Resident Environment
Penalty
Summary
The facility failed to maintain a clean and homelike environment for one resident and in 12 out of 15 rooms observed across two units. Specifically, the facility did not ensure that the 'room of the day' deep-cleaning was completed according to the established cleaning schedule. Observations revealed thick, dark gray dust on high surfaces such as overbed light fixtures and televisions in multiple rooms. A resident's representative expressed concerns about the lack of cleaning, and staff confirmed that the scheduled terminal cleaning had not been performed in the affected rooms. The Director of Housekeeping was unable to provide evidence of when these rooms were last terminally cleaned. Interviews with facility leadership, including the Director of Housekeeping, DON, and Infection Preventionist, revealed there was no process in place to monitor the cleanliness of the environment. The Administrator was unaware that the rooms had not been cleaned as scheduled and had not been informed when rooms were skipped. The DON recalled a previous family concern about high dusting areas but could not provide details. The failure to follow the cleaning schedule and lack of monitoring led to the observed deficiency in maintaining a safe, clean, and comfortable environment for residents.
Failure to Limit PRN Antipsychotic Use and Attempt Gradual Dose Reduction for Psychotropics
Penalty
Summary
The facility failed to ensure compliance with regulations regarding the use of psychotropic medications for two residents. For one resident with vascular dementia and mood disturbances, a PRN order for Haloperidol (an antipsychotic) was issued without a required 14-day limit or documented physician evaluation for continued use. The medication was administered on multiple occasions over several months, and the medical record did not include documentation supporting the extended use or a rationale from a provider. The Director of Nursing confirmed that the order lacked the necessary 14-day duration and supporting documentation for ongoing administration. For another resident with a diagnosis of depression, the facility did not attempt a Gradual Dose Reduction (GDR) for prescribed antidepressant medications, nor did it provide evidence that a GDR was clinically contraindicated. The resident had been receiving the same dosage of two antidepressants for over a year, and the medical record did not reflect any GDR attempts or physician documentation of contraindications. The Director of Nursing acknowledged that no GDR had been attempted and was unable to provide evidence to support that a GDR was considered or contraindicated.
Failure to Follow Physician Orders for Indwelling Catheter Care
Penalty
Summary
Facility staff failed to provide appropriate treatment and services for a resident with an indwelling urinary catheter by not following the physician's order regarding the correct catheter size. The resident, who was admitted with urinary retention and obstructive and reflux uropathy, was severely cognitively impaired and dependent on staff for activities of daily living. The physician's order specified a Foley catheter of 16 French with a 10 ml balloon, to be changed as needed for signs and symptoms of infection and routinely once a month. During observation, it was found that the resident had a 14 French Foley catheter in place, and the balloon size was faded and unreadable. Review of the Treatment Administration Record indicated that the catheter change was documented as completed with the correct size, but in reality, the catheter had not been changed as ordered. The Director of Nursing confirmed that the catheter in use did not match the current physician's orders and that the required catheter change had not occurred.
Failure to Provide Adequate Nutrition and Hydration
Penalty
Summary
A deficiency was identified regarding the facility's failure to provide adequate food and fluids necessary to maintain a resident's health. The report notes that the required provision of nutrition and hydration was not met, which is essential for the well-being of residents. Specific details about the actions or inactions leading to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Oxygen Therapy Administered Without Physician Order
Penalty
Summary
The facility failed to provide respiratory care and services in accordance with professional standards of practice for one resident. Specifically, a resident with diagnoses including Chronic Kidney Disease, Obstructive Sleep Apnea, Acute and Chronic Respiratory Failure with Hypoxia, and Chronic Obstructive Pulmonary Disease was observed receiving oxygen therapy at 4 liters per minute via nasal cannula. The resident reported always using oxygen at this rate, and the oxygen concentrator was observed in use during the survey. Upon review of the resident's medical record, there were no physician orders in place for the administration of oxygen therapy. Nursing staff and the Director of Nursing confirmed that oxygen was being administered without a physician's order, despite facility policy requiring all medications and treatments, including oxygen, to have a physician's order. The lack of a physician order for ongoing oxygen therapy constituted a failure to follow professional standards and facility policy.
Failure to Provide Safe and Appropriate Dialysis Care
Penalty
Summary
A deficiency was identified regarding the provision of safe and appropriate dialysis care and services for a resident who required such services. The facility failed to ensure that the necessary dialysis care was provided in accordance with the resident's needs. Specific details about the actions or omissions that led to this deficiency, as well as information about the resident's medical history or condition at the time, are not provided in the report.
Failure to Maintain Sanitation and Food Storage Practices in Kitchenettes
Penalty
Summary
Surveyors observed that the facility failed to ensure proper sanitation and food storage practices in both kitchenettes on the [NAME] Unit and [NAME] Unit. Specifically, refrigerators in these areas contained expired food items, such as sour cream, milk, instant Jello, and a supermarket packaged Cobb salad. Additionally, there were multiple unlabeled and undated resident food items, including milk, yogurts, juices, boiled eggs, cut fruits and vegetables, and an open stick of butter. The refrigerators also had spilled food and debris on the shelves, indicating a lack of regular cleaning and maintenance. Interviews revealed confusion and lack of clarity regarding departmental responsibilities for maintaining and cleaning the kitchenette refrigerators. The Food Service Director stated that the Dietary Department was not responsible for these refrigerators and did not maintain a cleaning schedule, believing housekeeping was responsible. The Housekeeping Director, newly employed, was unaware that his department was responsible for refrigerator cleaning and food item checks, and thus had no cleaning schedule in place. The Administrator confirmed that the Dietary Department should have been maintaining the refrigerators and checking for expired or unlabeled items, but this was not occurring. The Administrator also noted that staff and resident food items were improperly stored together and not properly labeled or dated.
Failure to Accurately Document PRN Medication Administration and Foley Catheter Care
Penalty
Summary
The facility failed to maintain accurate clinical records in accordance with professional standards for two residents. For one resident with chronic pain syndrome, the facility did not document the administration of a PRN dose of Tramadol, an opioid analgesic, on the Medication Administration Record (MAR) for a specific date and time, despite evidence from the narcotic book and nurse interview that the medication was given. Additionally, the effectiveness of the PRN Tramadol was not recorded as required by facility policy. The nurse involved acknowledged the omission and confirmed that both the administration and effectiveness should have been documented. For another resident with urinary retention and an indwelling Foley catheter, the facility failed to accurately document the size and care of the catheter. Although physician orders specified a 16 French catheter with a 10 ml balloon, observation revealed the resident had a 14 French catheter in place, and the balloon size was unreadable. The Treatment Administration Record (TAR) indicated that the catheter had been changed to the correct size on multiple occasions, but interviews with nursing staff and the Director of Nursing revealed that the documented catheter changes had not actually been performed, resulting in inaccurate records. These deficiencies were identified through observations, interviews, and record reviews, and were in direct violation of the facility's own policies regarding medication administration and catheter care documentation. The failures involved both the omission of required documentation and the inaccurate recording of care that was not provided.
Failure to Disinfect Glucometer with Required Bleach-Based Product
Penalty
Summary
Facility staff failed to properly implement infection control procedures when disinfecting a multi-use glucometer after use on a resident. Specifically, a nurse used Lysol wipes, which do not contain bleach, to clean the glucometer after performing a fingerstick blood sugar check on a resident with chronic respiratory failure, a tracheostomy, a gastrostomy tube, and type 2 diabetes. The nurse then returned the glucometer to the medication cart for use on other residents. The nurse stated she was unaware that a bleach-based product was required for disinfecting the device and routinely used Lysol wipes as provided by the facility. Facility policy and the manufacturer's operator manual for the Evencare G2 Meter both specify that a bleach-based disinfectant should be used to clean the glucometer, with a required dry time, to prevent the transmission of bloodborne pathogens. The Director of Nursing and Infection Preventionist confirmed that the facility had not updated its policy to reflect the manufacturer's guidelines after switching to the newer glucometer model, resulting in staff not following the correct disinfection protocol.
Failure to Establish Policies for Flu and Pneumonia Vaccinations
Penalty
Summary
The facility failed to develop and implement policies and procedures for administering flu and pneumonia vaccinations. This deficiency was identified through review of facility practices and documentation, which revealed the absence of established protocols to ensure residents received these vaccinations as recommended. There was no evidence that the facility had a systematic process in place to assess, offer, or document the administration or refusal of flu and pneumonia vaccines for residents.
Inaccurate MDS Assessments for Medications, Smoking, and Diet
Penalty
Summary
The facility failed to complete accurate Comprehensive Minimum Data Set (MDS) assessments for three residents, resulting in deficiencies in care planning and delivery. For one resident with vascular dementia and congestive heart failure, the facility did not accurately code the use of diuretic medication on the MDS, despite physician orders and medication administration records confirming the resident received a diuretic during the assessment period. The MDS nurse acknowledged that the medication should have been coded but was not. Another resident with chronic heart failure, morbid obesity, diabetes, and hypertension was incorrectly coded on the MDS as receiving anticoagulant medication, when in fact only antiplatelet medications (aspirin and clopidogrel) were ordered and administered. The MDS nurse admitted to misclassifying the medications, having assumed that clopidogrel was an anticoagulant, and this error was also reflected in the resident's care plan. Additionally, the facility failed to accurately code tobacco use and therapeutic diet status for two residents. One resident, identified as a smoker and care planned for smoking, was incorrectly coded as not using tobacco on the MDS, despite direct observation and interview confirming ongoing smoking. Another resident, with end stage renal failure and on dialysis, was not coded as receiving a therapeutic diet on two consecutive MDS assessments, even though physician orders indicated a prescribed therapeutic diet during the relevant periods. The MDS nurse confirmed these omissions.
Failure to Conduct Interdisciplinary Care Plan Meetings and Involve Residents
Penalty
Summary
The facility failed to conduct interdisciplinary care plan meetings after Minimum Data Set (MDS) assessments were completed and did not involve the residents or their representatives in the care planning process for four residents. Specifically, the facility did not provide evidence that Resident #2 and their invoked Health Care Proxy (HCP) participated in care planning meetings following MDS assessments completed on two occasions in 2024. The Social Worker (SW) was unable to provide documentation of care plan meetings or attendance records for these assessments, and the Administrator confirmed the absence of such evidence. For Resident #67, the facility did not provide evidence of care plan meetings or participation by the resident or their representative following an MDS assessment completed in January 2024. The resident reported not recalling any invitation or participation in care plan meetings, and the SW and Administrator were unable to provide documentation to support that such meetings occurred. Resident #3's clinical records did not show evidence of care plan meetings or participation by the resident or their representative following MDS assessments completed in December 2023 and March 2024. The resident was unaware of the existence of care plans, and the Administrator could not provide evidence of care plan meetings since December 2023. Similarly, Resident #60's records lacked evidence of care plan meetings following MDS assessments in May and August 2023, and the resident expressed a desire to discuss discharge planning but had not participated in any care plan meetings. The Administrator provided documentation of two care plan meetings in late 2023 and early 2024, but these did not include the resident's participation or an explanation for their absence.
Failure to Honor Resident's Meal Portion Request
Penalty
Summary
The facility failed to ensure that a resident's choices were honored when requested by his/her Resident Representative. Specifically, the facility did not evaluate whether the Resident Representative's request for double meal portions for a resident with Dementia with Behavioral Disturbance was appropriate, nor did they implement the request. The Resident Representative had repeatedly requested double meal portions, citing that the resident was always hungry during family visits. However, there was no follow-up from the facility staff on this request, and the resident continued to receive single meal portions as indicated by the current diet order and communication slip from the kitchen. Interviews with the Food Service Director and the Dietitian revealed that neither was aware of the request for double meal portions. The Food Service Director stated that she would have informed the Dietitian if she had known about the request, and the Dietitian would have assessed the appropriateness of increased portions. The Dietitian confirmed that she would evaluate such requests and provide education to the Resident Representative if increased portions were not suitable. However, no such evaluation or communication occurred in this case, leading to the deficiency.
Failure to Develop and Implement Care Plan for Resident's Behavior
Penalty
Summary
The facility failed to develop and implement a care plan for Resident #14, who exhibited behaviors of eating nonfood items and topical medications. Despite multiple documented incidents, including eating the foil covering off an applesauce cup and ingesting various topical medications such as anti-itch lotions and barrier creams, no care plan was created to address these behaviors. Interviews with staff and the resident's representative confirmed the resident's tendency to eat nonfood items, and the need for staff to ensure such items were not within the resident's reach. The Director of Nurses acknowledged that a care plan should have been developed to address Resident #14's behavior of eating nonfood items, but this was not done. The facility's policy on Behavioral Assessment, Intervention, and Monitoring requires the interdisciplinary team to evaluate behavioral symptoms and develop a care plan accordingly, which was not followed in this case. This oversight left staff without documented interventions to manage the resident's behavior, leading to repeated incidents of the resident ingesting nonfood items.
Failure to Provide Adequate Nutrition Care and Monitoring
Penalty
Summary
The facility failed to provide nutrition care and services that meet professional standards of practice for a resident receiving artificial nutrition via a Jejunostomy tube. Specifically, the facility staff did not appropriately implement, monitor, and evaluate weekly weights as ordered for the resident, nor did they reassess the resident's refusal to be weighed. Additionally, the staff failed to assess tube feed recommendations made by the Registered Dietitian (RD) and did not offer alternative options when the resident was unable to tolerate increased tube feeds and calorie goals. The resident, who was admitted with severe protein-calorie malnutrition, malignant neoplasm of the esophagus, and dysphagia, experienced significant weight loss. Despite the resident's refusal to be weighed on multiple occasions, the facility did not document reasons for the refusals or take appropriate actions to address the issue. The resident's weight was not consistently monitored, and there were gaps in the weekly weight records. The RD and nursing staff did not consistently reassess the resident's nutritional status or adjust the tube feeding regimen to meet the resident's needs. Interviews with the RD, nurses, and CNAs revealed that the resident's nutritional needs were not being met, and there was a lack of coordination and communication among the staff. The resident expressed concerns about their weight and willingness to trial an increase in tube feedings, but the facility did not take timely actions to address these concerns. The failure to monitor and adjust the resident's nutritional care contributed to the resident's continued weight loss and unmet nutritional goals.
Failure to Provide Appropriate Respiratory Care
Penalty
Summary
The facility failed to provide respiratory care and services consistent with professional standards of practice for two residents. For Resident #272, the facility staff did not ensure that the aerosol compressor was monitored and maintained for optimal humidification of the resident's tracheostomy tube. Additionally, there was no physician's order for oxygen use and increased liter flow, and the oxygen tubing equipment was not changed as required to prevent contamination and the spread of infections. Observations revealed that the aerosol compressor had run out of water, and the oxygen concentrator was set at 5 liters per minute without proper documentation or orders. The resident's respiratory equipment was also found lying on the floor, which was against the facility's protocol for maintaining sanitary conditions. For Resident #3, the facility staff failed to change the oxygen tubing and nebulizer tubing and mask as ordered. The resident's oxygen tubing and nebulizer tubing were observed to be dated and not changed weekly as required. Additionally, the nebulizer tubing and mask were placed directly on the resident's bedside table instead of being stored in a plastic bag with the resident's name and date. Interviews with the nursing staff confirmed that they were aware of the need to change the tubing and mask but had not done so. The Director of Nurses (DON) acknowledged that the facility did not have the necessary physician orders in place for Resident #272's oxygen use and that the respiratory equipment should have been stored properly. The DON also confirmed that the nebulizer masks and tubing for Resident #3 should be changed weekly and kept in a bag at the bedside. The facility's failure to adhere to these standards resulted in deficiencies in providing safe and appropriate respiratory care for the residents.
Failure to Monitor Hemodialysis Fistula
Penalty
Summary
The facility failed to provide services consistent with professional standards of practice related to hemodialysis for a resident with End Stage Renal Disease (ESRD). Specifically, the facility did not monitor the resident's AV fistula for signs and symptoms of patency and infection. The facility's policy required staff to be trained in the care and special needs of residents with ESRD, including the care of grafts and fistulas, and to document the condition of the fistula site every shift. However, the resident's physician orders did not include necessary nursing interventions for monitoring the fistula site, and the facility's progress notes did not reflect consistent monitoring for signs of infection or patency. The resident, who was cognitively intact, had a new fistula on the right lower extremity and received hemodialysis treatments three days a week. On one occasion, the resident returned from dialysis with significant bruising and swelling in the arm with the fistula, which prevented the dialysis treatment. The resident requested to go to the Emergency Department (ED) for evaluation, and the Nurse Practitioner agreed with this plan. The resident was subsequently hospitalized for several days and required surgery on the right arm. Interviews with the resident and nursing staff revealed that the resident had experienced issues with bruising and swelling at the fistula site. The Director of Nurses (DON) acknowledged that the physician's orders should have included monitoring the fistula for signs and symptoms of infection and patency from the time the fistula was placed, but these orders had not been initiated. This oversight led to the resident's condition worsening and requiring emergency medical intervention.
Medication Storage Deficiency
Penalty
Summary
The facility failed to ensure that medications were stored safely and remained inaccessible to a resident diagnosed with Dementia with Behavioral Disturbance. The resident ingested [NAME] Lotion, which was left unattended on the nurse's station desk, resulting in hospitalization. Additionally, the resident ingested a mixture of calamine, hydrocortisone, and zinc paste (house barrier cream) that was within reach during care, requiring monitoring for possible gastrointestinal upset. The facility's policy on medication storage was not adhered to, and no staff education was completed following these incidents. The Director of Nurses (DON) confirmed that nursing staff should not leave any medication unattended or within reach of residents. However, the DON was unable to provide documentation that staff education regarding proper medication storage was completed after the incidents. The Root Cause Analysis (RCA) indicated that the lotion and barrier cream were not stored securely, leading to the resident's ingestion of these substances. No additional interventions or education were documented to prevent recurrence.
Failure to Update Physician's Orders to Match MOLST
Penalty
Summary
The facility failed to maintain complete and accurate medical records for one resident out of 18 sampled. Specifically, the staff did not update the resident's Physician's orders to match the Massachusetts Medical Order for Life-Sustaining Treatment (MOLST). The resident, who was admitted with a diagnosis of Dementia with Behavioral Disturbance, had a MOLST indicating a Do Not Resuscitate (DNR) order. However, the Physician's orders in the electronic medical record (EMR) indicated the resident was a Full Code, which means all life-sustaining treatments, including CPR, should be performed. During an interview, a nurse confirmed that she would refer to the EMR to determine the resident's code status in case of cardiac distress. Upon review, the nurse found a discrepancy between the Physician's orders and the MOLST. The Physician's orders incorrectly indicated the resident was a Full Code, while the MOLST correctly indicated a DNR status. The nurse acknowledged that the Physician's orders should have been updated to match the MOLST when it was completed, but this update had not been made.
Failure to Implement Enhanced Barrier Precautions
Penalty
Summary
The facility failed to adhere to infection control standards for a resident with indwelling medical devices, specifically a tracheostomy and a gastrostomy tube. The staff did not identify the need for Enhanced Barrier Precautions (EBP) for this resident, which is required to reduce the transmission of multidrug-resistant organisms (MDROs). During an observation, a rehabilitation staff member assisted the resident without wearing the appropriate personal protective equipment (PPE), such as a gown, and there was no signage indicating EBP outside the resident's room. Interviews with the rehabilitation staff, the Assistant Director of Nursing (ADON), and the Director of Nurses (DON) revealed that the facility staff were aware of the EBP requirements but failed to implement them correctly. The ADON and DON confirmed that residents with wounds or indwelling medical devices should be on EBP and that proper signage should be in place to communicate the necessary precautions to staff. However, the required EBP signage was missing from the resident's room, leading to non-compliance with infection control standards.
Inaccurate MDS Coding for Pressure Ulcer and IV Hydration
Penalty
Summary
The facility failed to ensure that the Minimum Data Set (MDS) Assessments were accurately coded for two residents. For Resident #22, the MDS was not accurately coded to reflect the presence of a Stage Four pressure ulcer on re-admission to the facility. The resident, who had a diagnosis of Diabetes Mellitus with Autonomic Neuropathy, returned to the facility with a pressure ulcer on the coccyx. Despite this, the MDS Assessments dated 11/7/23 and 2/6/24 incorrectly indicated that the pressure ulcer was not present at the time of re-admission. The MDS Nurse confirmed that the assessments were coded incorrectly and should have reflected the pressure ulcer as present on re-admission and not facility-acquired. For Resident #29, the MDS was not accurately coded to reflect the use of IV hydration. The resident, who had a diagnosis of Dementia with Psychotic Disturbance, had a physician's order for IV hydration initiated on 2/27/24. The Nursing Progress Notes confirmed that the resident received 500 milliliters of normal saline through a peripheral line. However, the comprehensive MDS assessment did not indicate that the resident had received IV hydration during the assessment period. The MDS Nurse acknowledged that the assessment was coded incorrectly and needed to be modified.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Webster
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Webster Manor Rehabilitation & Health Care Center | 1.9 mi | ★★★★★ | 3 | 0 |
| Lanessa Extended Care | 1.9 mi | ★★★★★ | 1 | 0 |
| Overlook Masonic Health Center | 7.7 mi | ★★★★★ | 0 | 0 |
| Life Care Center Of Auburn | 8.2 mi | ★★★★★ | 1 | 0 |
| Southbridge Rehabilitation & Health Care Center | 8.5 mi | ★★★★★ | 8 | 0 |
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