BREWER CENTER FOR HEALTH & REHABILITATION, LLC
For profit - Partnership
111 Beds
NATIONAL HEALTH CARE ASSOCIATES
Data: November 2025
Trust Grade
58/100
#19 of 77 in ME
Photo by Kimmie Cockrell
Photo by Scott Miller
Photo by Brewer Center for Health & Rehabilitation
1 / 5 photos
Last Inspection: March 2025
Within standard 12-15 month inspection cycle. Federal law requires annual inspections.
Overview
Brewer Center for Health & Rehabilitation has a Trust Grade of C, indicating it is average in quality, which means it is in the middle of the pack among nursing homes. It ranks #19 out of 77 facilities in Maine, placing it in the top half, and #1 out of 11 in Penobscot County, meaning it is the best option locally. However, the facility is worsening, with issues increasing from 10 in 2024 to 12 in 2025. Staffing is a strong point, earning a 5/5 star rating with a turnover rate of 47%, slightly below the state average, suggesting that staff members are stable and familiar with the residents. On the downside, there have been serious incidents, including a resident falling and suffering a fracture due to improper transfer techniques and another resident experiencing anxiety from a mechanical lift incident. Additionally, there are concerns regarding the cleanliness of respiratory equipment, which may pose infection risks. Overall, families should weigh the strengths of stable staffing against the facility's recent issues.
- Trust Score
- C
- In Maine
- #19/77
- Safety Record
- Moderate
- Inspections
- Getting Worse
- Staff Stability ⚠ Watch
- 47% turnover. Above average. Higher turnover means staff may not know residents' routines.
- Penalties ✓ Good
- $8,648 in fines. Lower than most Maine facilities. Relatively clean record.
- Skilled Nurses ✓ Good
- Each resident gets 76 minutes of Registered Nurse (RN) attention daily — more than 97% of Maine nursing homes. RNs are the most trained staff who catch health problems before they become serious.
- Violations ⚠ Watch
- 37 deficiencies on record. Higher than average. Multiple issues found across inspections.
58/100
Top 24%
Needs review
10 → 12 violations
★★★★☆
4.0
Overall Rating
★★★★★
5.0
Staff Levels
★★★☆☆
3.0
Care Quality
★★★☆☆
3.0
Inspection Score
↔
Stable
2024: 10 issues
2025: 12 issues
The Good
-
5-Star Staffing Rating · Excellent nurse staffing levels
-
Full Sprinkler Coverage · Fire safety systems throughout facility
-
No fines on record
Facility shows strength in staffing levels, fire safety.
The Bad
Staff Turnover: 47%
Near Maine avg (46%)
Higher turnover may affect care consistency
Federal Fines: $8,648
Below median ($33,413)
Minor penalties assessed
Chain: NATIONAL HEALTH CARE ASSOCIATES
Part of a multi-facility chain
Ask about local staffing decisions and management
The Ugly 37 deficiencies on record
2 actual harm
Mar 2025
12 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to respect a resident's choice for the use of an incontinent product preference for 1 of 1 sampled resident (Resident #11 [R11]) who's inconti...
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Based on record review and interview, the facility failed to respect a resident's choice for the use of an incontinent product preference for 1 of 1 sampled resident (Resident #11 [R11]) who's incontinent product choice was denied.
Finding:
On 3/3/25, a review of R11's clinical record was completed. Documentation indicated that one of R11's medical concerns was incontinence.
On 3/3/25 at 11:50 a.m., in an interview with the surveyor, R11 stated they have always worn yellow colored incontinent briefs during the day and wears the white colored incontinent briefs at night. R11 stated the white briefs at night make him/her feel safer as not to leak urine and is more comfortable. R11 stated on Fridays, the supply clerk stocks her dresser drawer with yellow and white briefs to last her over the weekend. R11 stated this past Friday, 3/1/25, the supply clerk was not working and R11's drawer was not stocked with white briefs; all that was left were yellow briefs.
On 3/3/25 at 1:40 p.m., in an interview with the surveyor, the supply clerk stated he does stock R11's dresser with yellow briefs for the daytime and white briefs for night time use. He stated the briefs have the same absorbency but R11 prefer's the white briefs at night. He stated he was unable to stock the drawer on 3/1/25, because he was not working. He stated the nursing staff have two stock closets they can go too and get incontinent briefs.
On 3/3/25 at 2:10 p.m., in an interview with the surveyor, the evening/night Registered Nurse #3 (RN3), stated she did work this past week end. She confirmed that R11 asked her for white briefs for the night, but RN3 stated all she had was yellow briefs in her drawer and that was the color/size that fit her best. RN3 confirmed she did not provide R11 with any white briefs that weekend, even though R11 was asking for them.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0578
(Tag F0578)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the resident and/or resident representative was provide...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure that the resident and/or resident representative was provided with written information concerning the right to formulate an advanced directive, and/or ensure a resident's right to formulate an advanced directive regarding code status (cardiopulmonary resuscitation [CPR]) was accurate in the electronic record for 2 of 10 residents (Residents #98 [R98] and [R8]).
Findings:
1. During a record review R98 was admitted in January of 20251. A review of R98's paper and electronic clinical record lacked evidence that the facility offered or provided the resident and/or resident representative with written information concerning the right to formulate an advanced directive.
On [DATE] at 2:15 p.m., during an interview with the Director of Nursing and the Regional Clinical Director the surveyor confirmed that some new admissions that were admitted after the facility identified an issue with Advanced Directives in [DATE] and after they developed a plan to address Advanced directives with new admissions R98's clinical record lacked evidence that he/she was offered or provided with written information concerning the right to formulate an Advanced Directive.
2. On [DATE], R8'c clinical record was reviewed. R8's electronic chart indicates (Advanced Directives) Do Not Intubate, Do Not Resuscitate (Do not perform CPR). The (Advanced Directives) is a link to the scanned image of R8's signed Physician Orders for Life-Sustaining Treatment (POLST) form. R8's POLST form indicated Attempt Resuscitation/CPR.
On [DATE] at 12:10 p.m., during an interview with a surveyor and the Administrator, R8's code status and scanned POLST form were reviewed. The Administrator stated the POLST may be old and should be updated. At this time, the surveyor confirmed R8's advance directive regarding code status had conflicting information.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Notification of Changes
(Tag F0580)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to notify the physician of a change in condition after a resident developed blisters after an incident with spilled hot soup for 1 of 4 resi...
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Based on record reviews and interviews, the facility failed to notify the physician of a change in condition after a resident developed blisters after an incident with spilled hot soup for 1 of 4 residents reviewed for Accidents (Resident #203 [R203]).
Finding:
During a review of R203's clinical record and the facilities incident/accident reports. It was documented that R203 had an incident at 12:00 p.m. on 1/28/25. R203 nursing progress note documents that R203 accidentally dumped hot soup on his/her chest and upper abdomen. The chest and upper abdomen were reddened with a little bit of peeled skin. The provider was notified, and she gave a one-time order for topical bacitracin antibiotic.
On 1/31/25 at 3:54 p.m., documentation of a late entry for 1/30/25 on this day I was doing treatments on the coccyx and noticed the blisters on the chest going to the right side of the body /breast, was told he/she burnt self with the coffee from A wing, resident did not complain of discomfort to the area, evening supervisor also saw the blisters.
Review of R203's clinical records (paper and electronic) lacks evidence of a medical provider being made aware of the worsening of this burn and blisters developing. The Provider was made aware 5 days after the blisters were found.
Provider progress note dated 2/4/25 documented by the provider, documented that she was made aware of the wound from the burn 6 days after the burn occurred.
On 3/5/25 at 9:57 a.m., during an interview with the Director of Nursing, the surveyor confirmed that the Provider was not made aware of the change in the burn and the developing blisters until 2/4/25.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
PASARR Coordination
(Tag F0644)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to obtain recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination-Maine Summary of Findings for 1 o...
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Based on record review and interview, the facility failed to obtain recommendations from the Preadmission Screening and Resident Review (PASRR) level II determination-Maine Summary of Findings for 1 of 2 sampled resident's reviewed for PASRR evaluation (Resident #90 [R90]).
Finding:
R90's clinical record was reviewed and there was a PASRR Level I Screen Outcome, dated 11/26/24, that determined No Level II Required. R90's PASRR Level I Screen Outcome dated 11/26/24 did not include all R90's diagnoses.
R90's care plan dated 12/16/24 was reviewed and stated, Focus: PASRR outcome: referred for Level II, awaiting assessment completion. Date initiated: 12/12/24; under Goal: Monitor resident for need of new PASRR screening throughout assessment period; and, under Interventions: Request PASRR screening as needed.
On 3/6/25 at 1:45 p.m., during an interview with the Social Worker (SW), a surveyor requested additional information about if another PASRR screening was completed for R90. The SW obtained a copy of R90's PASRR Level I Screen Outcome determination dated 12/2/24 that stated to refer R90 for Level II onsite, and stated, shows that you need a face-to-face Level II evaluation, and obtained a copy of R90's PASRR Level II. The surveyor confirmed at this time that the facility did not have the PASRR Level II determination until 3/6/25.
On 3/6/25 at 1:45 p.m., during an interview with a surveyor, the Social Worker (SW) stated that a PASRR Level I screen was resubmitted on 12/3/24 with additional diagnoses but did not have the outcome of the screening. The SW was able to obtain the PASRR Level II recommendations on 3/6/25, and a surveyor confirmed that the SW was responsible to obtain these services and could not find documentation that indicated that these services had been offered or refused.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a resident with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropr...
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Based on record review and interview, the facility failed to ensure a resident with a specialized mental health diagnosis, whose stay went beyond the expected 30 days, had been referred to the appropriate state-designated authority for Pre-admission Screening & Resident Review Level II (PASRR) evaluation and determination for 1 of 3 residents reviewed for PASRR (Resident #24 [R24]).
Finding:
On 3/6/25, clinical record review indicated R24 was admitted in December of 2024. Admitting diagnosis included Anxiety Disorder, Major Depression, and Obsessive Compulsive Disorder (OCD). Review of R24's PASRR, dated 10/28/24, indicated R24 had a Convalescence Categorical exemption (a time-limited 30 day exemption). Review of R24's care plan for PASRR, initiated 1/2/25 indicated, Will submit reassessment if resident remains in facility after 30 days of admission
On 3/6/25 at 10:52 a.m., during an interview with a surveyor and the Social Worker (SW), the clinical record for R24 was reviewed. At this time the SW confirmed R24 was not referred for a PASARR level II determination after the 30 day Convalescence period ended.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected 1 resident
Based on observations, interviews and record review, the facility failed to provide recommended nutritional services to 1 of 1 resident (Resident #258 [R258]) observed during mealtimes for 1 of 3 lunc...
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Based on observations, interviews and record review, the facility failed to provide recommended nutritional services to 1 of 1 resident (Resident #258 [R258]) observed during mealtimes for 1 of 3 lunch meals observed (3/3/25, lunch).
Finding:
During an initial observation of R258 on 3/3/25 at approximately 12:50 p.m. and interview with R258's spouse, the spouse remarked that R258 hasn't had lunch yet and that a lunch tray usually comes by 12:30 p.m.
The surveyor observed a closed lunch cart in the hallway and on 3/3/25 at 1:20 p.m. in an interview with a surveyor, the LPN, charge nurse stated that all trays were passed and confirmed at this time that R258 did not receive a lunch meal.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to follow up on pharmacist recommendations timely, for 1 of 5 residents reviewed for unnecessary medications (Resident #53 [R53]).
Finding:
On...
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Based on record review and interview, the facility failed to follow up on pharmacist recommendations timely, for 1 of 5 residents reviewed for unnecessary medications (Resident #53 [R53]).
Finding:
On 3/6/25, a review of R53's clinical record was completed. Documentation in the physician orders indicated the resident had an insulin (Novolog) sliding scale for insulin coverage on Mondays, Wednesdays and Fridays (a sliding scale is the amount of insulin to be administered changes or slides up or down based on the persons blood sugar).
A review of the pharmacist recommendations, dated 12/31/24 and 2/26/25 indicated the pharmacist recommendation for 12/21/24 was to confirm the Novolog sliding scale for Mondays, Wednesdays, and Fridays because there was no insulin coverage for the other days of the week. Documentation next to this recommendation indicated no changes to this order, but there was no evidence as to when this documentation occurred.
On 2/26/25, during the pharmacist's monthly visit, again made a recommendation to confirm the Novolog sliding scale for Mondays, Wednesdays, and Fridays because there was no insulin coverage for the other days of the week.
On 3/5/25, a provider responded to the pharmacist's recommendation, 64 days after the original recommendation was made.
On 3/6/25 at 8:10 a.m., in an interview with the Director of Nursing, she confirmed that the 12/31/24 response to the pharmacy recommendation had no evidence when done and that the siding scale was not responded to and dated until 3/5/25.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to ensure medications were labelled, stored at the appropriate temperature, and secured properly by having an unlocked, unattended medication ca...
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Based on observation and interview, the facility failed to ensure medications were labelled, stored at the appropriate temperature, and secured properly by having an unlocked, unattended medication cart allowing residents and unauthorized persons access to medications on 1 of 3 survey days (3/5/25).
Findings:
On 3/5/25 at 9:31 a.m., during review of the B-unit Treatment Cart #1, a surveyor and the Unit Manager #1 (UM1) observed, an unopened Basaglar KwikPen (insulin glargine) 100 units (u) / milliliter (mL) was observed in the top drawer. The 3 mL pre-filled syringe was labeled with a refrigerate sticker. The UM stated it should be stored in the refrigerator until it is used.
On 3/5/25 at 9:42 a.m., during review of the B-unit Medication Cart #1, a surveyor and Certified Nursing Assistant-Medications (CNA-M) observed:
-a box labeled Breyna (Budesonide Formoterol Fumarate) 80 microgram (mcg)/ 4.5 mcg. The box was observed to contain 2 inhaler devices. One device had a dose of 80 mcg /4.5 mcg, the second device has a dose of 160 mcg/4.5 mcg and labeled with R53's initials. Review of R53's electronic record revealed an order for Budesonide Formoterol Fumarate 80 mcg/4.5 mcg.
-a Trelegy Ellipta inhaler was observed unlabeled and stored inside a Breo-Ellipta box labelled as belonging to R14. CNA-M stated the Trelegy inhaler belongs to R15, as he/she is the only resident who has Trelegy. An unlabeled Breo-Ellipta inhaler was observed loose in the medication drawer, CNA-M stated that Breo-Ellipta inhaler belongs to R14.
During this review, CNA-M stated individual inhalers, and nasal sprays are unlabeled as the facility labels patient identifier and expirations on the container box(s) only.
On 3/5/25 at 10:29 a.m., during review of the treatment cart on the ABI unit, a surveyor and Unit Manager #2 (UM2) observed:
-the treatment cart was unattended and left unlocked in the hallway where residents have direct access. The cart contains insulin(s) and sharps in addition to dressings and ointments.
-1 multidose 10ml vial of Lantus (Insulin Glargine) 100u/mL , opened and unlabeled.
-2 pre-filled 3mL insulin pen labeled Lantus Solostar (Insulin Glargine) 100u/mL stored in a bag. One of the insulin pens was labeled with conflicting open dates (cap labelled with an open date of 2/24, pen base labelled as opened 3/3/25), the second insulin pen was unopened/unlabeled, and not stored in the refrigerator. UM2 stated the pen should have been stored in the refrigerator when it was received.
On 3/5/25 at 10:45 a.m., during review of the A-wing treatment cart, a surveyor and UM2 observed, 1 pre-filled 3mL insulin pen labeled Insulin Lispro 100u/mL, unlabeled / unopened, stored in a bag with a sticker indicating it should be refrigerated. UM2 stated that it should have been stored in the refrigerator.
On 3/6/25, review of the Storage of Medication policy indicated under the procedures heading, 12. Insulin vials should be stored in the refrigerator until opened. Date insulin vials when first opened. May store opened vial in refrigerator or at room temperature.
The above findings were observed and confirmed at the time of the finding.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Dental Services
(Tag F0791)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to obtain dental services for a resident with broken teeth for 1 of 1 residents reviewed for dental services (Resident #8 [R8]).
Finding:
On...
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Based on record reviews and interviews, the facility failed to obtain dental services for a resident with broken teeth for 1 of 1 residents reviewed for dental services (Resident #8 [R8]).
Finding:
On 3/4/25 at 3:00 p.m., during an interview with R8, a surveyor observed R8's gums appeared red and enflamed with several broken teeth with visible decay. R8 stated they were painful.
On 3/6/25, Review of R8's clinical record revealed the following:
- On 3/31/16 the care plan was revised to include focus area The resident has oral/dental health problems [related to] Poor oral hygiene. The Intervention for this care area indicates Coordinate arrangements for dental care, transportation as needed/as ordered, and Document /report [as needed] any [signs or symptoms] of oral/dental problems needing attention: Pain .Teeth missing, loose, broken, eroded, decayed, .
-On 5/29/24 the Pre-Care Conference Review Form indicated [R8] asks about dentist appt daily.
-On 7/16/24 at 11:25 p.m., the provider wrote in a regulatory review note, When I ask how [R8] is doing, [R8] tells me he/she wants false teeth. I tell [R8] that it can be difficult to get insurance to pay for them, but that I can ask [Social Worker] about it.
-On 7/25/24 at 2:36 p.m., the provide wrote in a progress note, poor dentition, missing several teeth, remaining teeth with visible decay.
-On 8/12/24 at 10:38 a.m., the Care Plan Meeting note indicated R8 Has complained of oral pain recently.
On 3/6/25 at 12:25 p.m., during an interview with a surveyor and the Director of Nursing, R8's clinical record was reviewed. At this time the surveyor confirmed the medical record lacked evidence that the facility addressed R8's dental concerns and/or requests for dental services.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Respiratory Care
(Tag F0695)
Could have caused harm · This affected multiple residents
Based on observation, record review, and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection...
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Based on observation, record review, and interview, the facility failed to maintain respiratory equipment in a sanitary manner to help prevent the development and transmission of disease and infection related to respiratory care for 5 of 8 residents reviewed on survey (Resident #14 [R14], [R40] [R29], [R32], and [R82]).
Findings:
1. On 3/3/25 at 12:36 p.m., a surveyor observed R14's oxygen concentrator filters to be heavily soiled with dust/debris. Record review indicates R14 receives oxygen 2 liters (L) / minute (min) continuously for the diagnosis of Chronic Respiratory Failure with Hypoxia (inadequate oxygen to the body), and Chronic Obstructive Pulmonary Disease (COPD).
2. On 3/3/25 at 12:40 p.m., a surveyor observed R40's oxygen concentrator filter to be heavily soiled with dust/debris. Record review indicates R40 receives oxygen 4 L/min continuously for the diagnosis of Chronic Respiratory Failure with Hypoxia, Chronic Respiratory Failure with Hypercapnia (elevated levels of carbon dioxide in the blood), and COPD.
3. On 3/3/25 at 1:32 p.m., a surveyor observed R29's oxygen concentrator filter to be heavily soiled with dust/debris. Record review indicates R29 receives oxygen 1-2 L/min continuously for shortness of breath related to Acute and Chronic Respiratory Failure with Hypoxia, and COPD.
4. On 3/3/25 at 2:28 p.m., a surveyor observed R32's oxygen concentrator filter to be heavily soiled with dust/debris. Record review indicates R32 receives oxygen 2 L/min continuously for Chronic Respiratory Failure with Hypoxia.
5. On 3/3/25 2:33 p.m., a surveyor observed R82 wearing oxygen tubing attached to an oxygen concentrator. The concentrator did not appear to be functioning. The concentrator filter was observed to be heavily soiled with dust/debris.
On 3/3/25 at 2:41 p.m., during an interview with a surveyor and the RN Supervisor, R82's concentrator was observed. The RN Supervisor confirmed the machine was not turned on, and stated that the machine should be running continuously.
On 3/5/25 at 1:48 p.m., during an interview with the Administrator, a surveyor confirmed above residents oxygen concentrator filters was heavily soiled with dust /debris.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0711
(Tag F0711)
Could have caused harm · This affected multiple residents
Based on clinical record reviews and interview, the facility failed to ensure the attending physician made required visits, at least every 60 days for 6 of 8 sampled residents (Resident #1 [R1], [R25]...
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Based on clinical record reviews and interview, the facility failed to ensure the attending physician made required visits, at least every 60 days for 6 of 8 sampled residents (Resident #1 [R1], [R25], [R37], [R40], [R8], and [R3]).
Findings:
1. On 3/5/25, a review of R1's clinical record indicated that R1's last physician visit was on 11/26/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders was due on 2/5/25. The block orders were signed on 3/4/25; signed 26 days late.
2. On 3/5/25, a review of R25's clinical record indicated that R25's last physician visit was on 11/26/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders was due on 2/5/25. The block orders were signed on 3/4/25; signed 26 days late.
On 3/5/25 at 11:45 a.m., in an interview with the surveyor, the Director of Nursing, confirmed that the last required physician visit to sign the 60 day orders was 26 days late.
3. On 3/5/25, a review of R37's clinical record indicated that R37's last physician visit was on 12/10/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders, was due on 2/18/25.
On 3/6/25 at 10:50 a.m., during an interview with a surveyor and the DON, the clinical record for R37 was reviewed. At this time, the DON confirmed that the last required physician visit to sign the 60 day orders was 14 days late.
4. On 3/5/25, a review of R40's clinical record indicated that R40's last physician visit was on 11/7/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders, was due on 1/16/25.
On 3/6/25 at 10:50 a.m., during an interview with a surveyor and the DON, the clinical record for R40 was reviewed. At this time, the DON confirmed that the last required physician visit to sign the 60 day orders was 47 days late.
5. On 3/5/25, a review of R8's clinical record indicated that R8's last physician visit was on 11/21/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders, was due on 1/30/25.
On 3/6/25 at 10:50 a.m., during an interview with a surveyor and the DON, the clinical record for R8 was reviewed. At this time, the DON confirmed that the last required physician visit to sign the 60 day orders was 34 days late.
6. On 3/5/25, a review of R3's clinical record indicated that R3's last physician visit was on 12/3/24, in which the physician signed the medication block orders. The next 60 day physician visit, including a 10-day grace period, which required the physician to sign the 60 day block orders, was due on 2/11/25.
On 3/6/25 at 10:50 a.m., during an interview with a surveyor and the DON, the clinical record for R8 was reviewed. At this time, the DON confirmed that the last required physician visit to sign the 60 day orders was 22 days late.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0730
(Tag F0730)
Could have caused harm · This affected multiple residents
Based on performance evaluation reviews and interview, the facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant...
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Based on performance evaluation reviews and interview, the facility failed to complete annual performance evaluations at least every 12 months for 1 of 5 sampled employees (Certified Nursing Assistant #1 [CNA1], CNA2, CNA3, CNA4).
Findings:
1. CNA1 was hired on 11/7/2015. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024.
2. CNA2 was hired on 8/29/2020. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024.
3. CNA3 was hired on 3/19/2003. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024.
4. CNA4 was hired on 6/18/2020. The facility was unable to provide evidence of completed annual performance evaluations for 2023 and 2024.
On 3/6/24 at 2:40 p.m., in an interview with a surveyor, the Director of Nursing confirmed that the above CNA's annual performance evaluations for 2023 and 2024 were not completed.
Feb 2024
10 deficiencies
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0645
(Tag F0645)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), included current diagnosis, and was updated for 1 of 6 residents reviewed (Re...
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Based on record review and interview, the facility failed to ensure a Pre-admission Screening and Resident Review (PASRR), included current diagnosis, and was updated for 1 of 6 residents reviewed (Resident #52 [R52]).
Finding:
During review of R52's medical record it contained a PASRR Level I Screen dated 8/10/23. The PASRR Level I Screen in the diagnosis section, did not include a current diagnosis of bipolar disorder. R52's current diagnosis list includes a diagnosis of bipolar disorder. The resident record lacked evidence that the PASRR Level I Screen was updated to include his/her diagnosis of bipolar disorder and was resubmitted/forwarded to the State-designated authority to determine if a Level II assessment was needed.
On 2/14/24 at 12:50 p.m during an interview with the Licensed Social Worker, the surveyor confirmed that the PASRR Level I for R52 did not include a diagnosis of bipolar disorder and was not resubmitted to PASRR for an updated Level II.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
2. On 2/14/24, R21's physician orders and February's Medication Administration Record (MAR) was reviewed. The physician orders included an order, dated 8/15/23, to administer Insulin Detemir 20 units ...
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2. On 2/14/24, R21's physician orders and February's Medication Administration Record (MAR) was reviewed. The physician orders included an order, dated 8/15/23, to administer Insulin Detemir 20 units two times a day (8 a.m. and 8 p.m.) but to hold if the blood sugar (BS) was less than 120. A review of the February MAR indicated:
On 2/7/24 at 7:30 a.m., the BS was 120 but documentation indicated the insulin was not given.
On 2/7/24 at 8:00 p.m., the BS was 105 but documentation indicated the insulin was given.
On 2/10/24 at 7:30 a.m., the BS was 86 but documentation indicated the insulin was given.
On 2/14/24 at 2:29 p.m., during an interview with a surveyor, the Assistant Director of Nursing was unable to find any additional information on why the insulin was given outside of the parameters. The surveyor confirmed this finding.
Based on interviews and record review, the facility failed to follow Physician orders for 1 of 1 sampled Resident receiving dialysis. (Resident #203, [R203]) and 1 of 2 sampled residents reviewed with insulin parameters [R21].
Findings:
1 On 2/13/24, during an interview with R203 and his/her family member, they stated that R203 is not receiving their medications (specifically their binding medications) at the correct times. R203 stated the medications are supposed to be given with meals and he/she is getting them either before a meal or after meals. A review of R203's clinical record was completed; the electronic medication administration record (eMAR) shows an order for Sevelamer Carbonate Oral Tablet 800 Milligram (mg) with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food.
Sevelamer works by holding onto phosphate from the diet so that it can pass out of the body.
Review of the meal caddie arrival times was reviewed with the Food Service Director to identify the approximate time R203 would receive his/her meals. R203 resides on the Rehab1 unit, for the breakfast meal the food caddie for Rehab 1 reaches the unit at 7:15 a.m., the trays are then delivered to the residents rooms. For the lunch meal the food caddie goes to the Rehab 1 unit at 11:15 a.m. and trays are delivered to the rooms then, for supper meal the food caddie goes to the Rehab 1 unit at 4:15 p.m.
Upon review of the administration detail report for Sevelamer Carbonate 800 mg it documents that on the following days R203 did not receive this medication as ordered (with food).
On 2/6/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 8:45 a.m., 1.5 hours after his/her breakfast meal and not administered with his/her meal.
On 2/6/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 12:53 p.m., 1.5 hours after his/her lunch meal.
On 2/7/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 7:56 a.m., 45 minutes after his/her breakfast meal.
On 2/8/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 1:25 p.m., 2 hours and 10 minutes after his/her lunch meal.
On 2/9/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 10:31 a.m., 45 minutes before his/her lunch meal.
On 2/11/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at10:35 a.m., 45 minutes before his/her lunch meal.
On 2/13/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 9:16 a.m., 2 hours after his/her breakfast meal.
On 2/13/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 2:52 p.m., 3.5 hours after his/her lunch meal.
On 2/13/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 3:56 p.m., 20 minutes before his/her supper meal.
On 2/14/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 10:36 a.m., 45 minutes before his/her lunch meal.
On 2/14/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 3:43 p.m., 30 minutes before his/her supper meal.
On 2/15/24, R203 received the medication (Sevelamer Carbonate Oral Tablet 800 MG with instructions to give 1 tablet by mouth with meals related to end stage renal disease and to give with first bite of food) at 6:54 a.m., 20 minutes before his/her breakfast meal.
02/15/24 at 11:24 a.m., during an interview with the charge nurse, the surveyor and the charge nurse reviewed the administration times R203 received the medication Sevelamer. It was confirmed at that time that Sevelamer was given this a.m. at 6:50 and again at 10:30 a.m., and on 2/14/24 the previous night he/she received it at 3:58 p.m., the surveyor confirmed the order does say to be given with meals.
02/15/24 at 11:29 a.m., during an interview with the Director of Nursing, a surveyor reviewed the medication administration times for R203's Sevelamer medication, the last 10 days were reviewed showing documentation that R203 has not been receiving the medication Sevelamer as ordered with meals or first bite. The above findings were confirmed at this time.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Tube Feeding
(Tag F0693)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to tube feedings, for 1 of 1 sampled resident reviewed with a fe...
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Based on record review and interview, the facility failed to provide appropriate treatment to prevent the risk of complications related to tube feedings, for 1 of 1 sampled resident reviewed with a feeding tube (Resident#39 [R39]).
Finding:
On 2/13/24, R39's clinical record was reviewed for January and February 2024 for treatments related to the resident's feeding tube. The Treatment Administration Record (TAR) contained a treatment, dated 1/25/22, that directed staff to check placement of feeding tube prior to each use (to be done on each 12 hour shift) and a treatment, dated 7/15/23, to check residual before starting the tube feed (TF) and every 8 hours while TF was running, to be checked at 7:00 p.m. and 3:00 a.m.
A review of January's TAR indicated:
On 1/3/24 at 3:00 a.m., there was no evidence of the residual being checked.
On 1/15/24 at 3:00 a.m., there was no evidence of the residual being checked.
On 1/19/24 during the 7 p.m. - 7 a.m., the placement check of the feed tube lacked evidence of it being checked.
On 1/20/24 at 3:00 a.m., there was no evidence of the residual being checked.
A review of February's TAR indicated:
On 2/2/24 at 7:00 p.m., there was no evidence of the residual being checked.
On 2/8/24 at 3:00 a.m., there was no evidence of the residual being checked.
On 2/13/24 at 7:00 p.m., there was no evidence of the residual being checked.
On 2/14/24 at 10:01 a.m., during an interview with a surveyor, the Regional Director of Clinical Operations stated she was unable to find evidence that the placement or residual was checked for the above dates/times. The surveyor confirmed this finding.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Pharmacy Services
(Tag F0755)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure that a physician's order for Ambien (a medication used to treat insomnia) was available and administered for 1 of 1 sampled resident...
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Based on record review and interview, the facility failed to ensure that a physician's order for Ambien (a medication used to treat insomnia) was available and administered for 1 of 1 sampled residents (Resident #11[R11]).
Finding:
On 2/12/24, record review indicated R11 had a physician's order for Ambien 5 milligrams (mg) to be given at 8:00 p.m. for insomnia beginning 1/29/24. Documentation on R11's Medication Administration Record (MAR) indicated that on 1/31/24, 2/1/24, 2/2/24, 2/3/24, 2/4/24, 2/5/24, and 2/7/24 (7 days) Ambien was not given due to the medication being unavailable.
On 2/14/24 at 9:48 a.m., in an interview with the Assistant Director of Nursing (ADON), she stated the resident did not receive the medications in relation to a missing delivery.
On 2/14/24 at 11:17 a.m., in an interview with the Regional Director (RD) and the ADON, the RD stated the Ambien administered on 2/6/24 came from the Cubex (facility reserve supply). She stated the Cubex had a stock of 4 doses and does not know why staff did not use this for the other days missed.
On 2/14/24 at 11:17 a.m., in an interview, the surveyor confirmed with the RD and ADON that the Ambien was not administered as physician ordered and that the facility did not ensure Ambien was available.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Drug Regimen Review
(Tag F0756)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the pharmacist identified an irregularity for as needed (PRN) psychotropic medication use for 1 of 5 residents reviewed for unnecess...
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Based on record review and interview, the facility failed to ensure the pharmacist identified an irregularity for as needed (PRN) psychotropic medication use for 1 of 5 residents reviewed for unnecessary medications (Resident#35 [R35]).
Finding:
On 2/14/24, R35's clinical record was reviewed. The surveyor reviewed physician orders from November 2023 to current and observed that the facility was renewing PRN Risperdal (anti-psychotic psychotropic medication) prior to the Medical Provider re-examining the resident to determine if the medication was still needed. On 2/14/24 at 3:50 p.m., during an interview with the Regional Director of Clinical Services, a surveyor confirmed that the PRN Risperdal is being renewed the day before the physician re-examined the resident. The Regional Director of Clinical Services and surveyor reviewed the most recent pharmacist review for R35, completed on 1/30/24, and was noted that there were no inconsistencies for the medication regimen review and did not identify this irregularity.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Medication Errors
(Tag F0758)
Could have caused harm · This affected 1 resident
Based on record review and interview, the facility failed to ensure the physician examined a resident to determine if an as needed (PRN) anti-psychotic medication was still needed before writing a new...
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Based on record review and interview, the facility failed to ensure the physician examined a resident to determine if an as needed (PRN) anti-psychotic medication was still needed before writing a new order to renew the same PRN anti-psychotic medication for 1 of 5 residents reviewed for unnecessary medications (Resident#35 [R35]).
Findings:
On 2/14/24, R35's clinical record was reviewed and contained a physician order to administer Risperdal (anti-psychotic) 0.5 milligrams, every 12 hours as needed.
The physician orders contained an order for the PRN Risperdal which started on 11/27/23 with an end date of 12/11/23. The physician visited R35 on 12/12/23 but the PRN Risperdal was restarted on 12/11/23 at 2:04 p.m., prior to the examination of the resident.
The physician orders contained an order for the PRN Risperdal which was renewed on 12/28/23 with an end date of 1/11/24. The physician visited R35 on 12/29/23 but the PRN Risperdal was renewed on 12/28/23 at 1:12 p.m., prior to the examination of the resident.
The physician orders contained an order for the PRN Risperdal which was renewed on 1/11/24 with an end date of 1/25/24. The physician visited R35 on 1/12/24 but the PRN Risperdal was renewed on 1/11/24 at 2:36 p.m., prior to the examination of the resident.
The physician orders contained an order for the PRN Risperdal which was renewed on 1/25/24 with an end date of 2/8/24. The physician visited R35 on 1/26/24 but the PRN Risperdal was renewed on 1/25/24 at 3:41 p.m., prior to the examination of the resident.
The physician orders contained an order for the PRN Risperdal which was renewed on 2/8/24 with an end date of 2/22/24. The physician visited R35 on 2/9/24 but the PRN Risperdal was renewed on 2/8/24 at 2:54 p.m., prior to the examination of the resident.
On 2/14/24 at 3:50 p.m., during an interview with the Regional Director of Clinical Services, a surveyor confirmed that the PRN Risperdal is being renewed the day before the physician re-examined the resident.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Unnecessary Medications
(Tag F0759)
Could have caused harm · This affected 1 resident
Based on observations, record reviews, and interview, the facility failed to be free of medication error rate of 5% or more. There were a total of 2 medication errors out of 28 opportunities for (Resi...
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Based on observations, record reviews, and interview, the facility failed to be free of medication error rate of 5% or more. There were a total of 2 medication errors out of 28 opportunities for (Resident #57 [R57]) and (Resident #[R205]). The medication error rate was 7.14%.
Findings:
1. On 2/13/24 at 8:10 a.m., a surveyor observed Licensed Practical Nurse#1 (LPN1) prepare medications for R57. The medications included Metoprolol 12.5 milligrams (mg), and Wixela Fluticasone Salmeterol 500/50 (a metered dose inhaler), ordered to give 1 inhale orally 2 times per day. Prior to entering R57's room, LPN1 labelled the medicine cup, then placed it in the top drawer of the cart, she placed the inhaler in a separate side drawer of the cart. LPN1 entered R57's room to obtain a blood pressure. The resident was observed to be short of breath, R57 stated he/she accidentally spilled something and had been attempting to clean it up. LPN1 asked a Certified Nursing Assistant to assist with clean-up and requested R57 remain seated and relaxed to recover. After obtaining the blood pressure, LPN1 returned to the cart, removed the medicine cup, and gave the medications to R57. R57 requested the inhaler after taking the medications. LPN1 confirmed she would get the inhaler. After leaving R57's room LPN1 performed hand hygiene and began to wheel the medicine cart away from R57's room to the next location. At this time the surveyor intervened and reminded R57 had requested the inhaler. LPN1 stated Oh yeah, I forgot.
2. On 2/13/24 at 8:32 a.m., a surveyor observed LPN1 prepare medications for R205 which included an order for Venlafaxine Extended Release (ER) 37.5 mg tablet. LPN1 placed a Venlafaxine tablet into the medicine cup at two separate times during the medication pass from two separate pharmacy medication cards, making the dose 75 mg for administration.
On 2/13/24 at 9:25 a.m., during record review of R205 clinical record the surveyor discovered the order for Venlafaxine ER 37.5 mg, one tablet to be given orally once per day. Reviewed finding with LPN1, who reviewed both pharmacy cards and confirmed the error.
On 2/13/24 at 9:30 a.m., in an interview with LPN1, the surveyor confirmed two medication errors were made during the medication administration.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0761
(Tag F0761)
Could have caused harm · This affected 1 resident
Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use, and tube feeding supplies were stored in a sanitary manner in 1 ...
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Based on observations and interviews, the facility failed to ensure expired medications were removed from the supply available for use, and tube feeding supplies were stored in a sanitary manner in 1 of 2 medication rooms reviewed (Medication Storage Room on Wing B).
Finding:
On 2/12/24 at 12:12 p.m., during a review of the Medication Storage Room on Wing B, the surveyor observed 1 unopened box of Humulin N (NPH isophane insulin human suspension) 100 units/milliliter (mL),10 mL container, with an expiration date of 10/2023 in the fridge available for use, and 1 bottle of Vital 1.5 cal (1.5 calories per mL) 1000 mL peptide base, Therapeutic Nutrition for Tolerance, was observed on the shelf available for use with a missing protective cap and a damaged seal. These were confirmed at the time of finding with the Certified Nursing Assistant Medication Aide (CNA-M).
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Infection Control
(Tag F0880)
Could have caused harm · This affected 1 resident
Based on observation and interview, the facility failed to implement appropriate infection prevention at point-of-care testing when Certified Nurse Assistant #2 (CNA2) did not apply gloves for a finge...
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Based on observation and interview, the facility failed to implement appropriate infection prevention at point-of-care testing when Certified Nurse Assistant #2 (CNA2) did not apply gloves for a fingerstick procedure during blood glucose testing for 1 of 1 observation (2/15/24).
Finding:
On 2/15/24 at 10:53 a.m., during an interview with Resident #26 (R26) and family, CNA2 entered the room and requested to perform a glucose test on R26. The family interview was temporarily placed on hold and the surveyor observed the blood glucose testing procedure which was performed without the use of gloves.
A review of the facility's procedures indicates the use of gloves to clean the glucometer prior to use, remove gloves and wash hands, then apply clean gloves, insert test strip into meter, obtain a drip of blood (wipe finger with alcohol prep then wipe same finger with tissue before pricking finger), apply blood to test strip.
On 2/15/24, at approximately 11:45 a.m., a surveyor confirmed with the Director of Nursing that CNA2 was not following infection prevention practices and that the break in infection control included not wearing gloves when performing blood glucose testing.
MINOR
(B)
Minor Issue - procedural, no safety impact
Deficiency F0883
(Tag F0883)
Minor procedural issue · This affected multiple residents
Based on review of the facility's 'Influenza Immunization Policy,' admission Influenza Consent form and interview, the facility failed to provide the Resident and/or the Resident's Representative with...
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Based on review of the facility's 'Influenza Immunization Policy,' admission Influenza Consent form and interview, the facility failed to provide the Resident and/or the Resident's Representative with the Vaccine Information Statement (VIS)' prior to immunizing a resident with the influenza vaccine for all residents receiving the influenza vaccine who are not new admissions.
Finding:
On 2/15/24, the facility's Infection Prevention and Control Program was reviewed and the immunization policy and procedure indicated residents will be offered the influenza vaccination yearly following the Centers for Disease Control and Prevention (CDC) guidelines.
On 2/15/24 at 11:14 a.m., in an interview with the surveyor, the facility's Infection Preventionist (IP) stated that upon admission, the admission packet contains a consent form with information explaining the risks versus the benefits (called the VIS) of having the influenza vaccination. The IP stated she thought that this one consent form and VIS is good for the entire stay of the resident and was unaware that a VIS should be provided to the Resident or Resident Representative prior to vaccination. The IP confirmed that the Resident and/or Resident Representative did not receive the VIS this year prior to the administration of the influenza vaccination.
Oct 2023
2 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise and implement an individualized person-centered care plan to...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to revise and implement an individualized person-centered care plan to render trauma informed care to a resident with a personal history of trauma related to verbal abuse and bullying for 1 of 1 residents reviewed (Resident #1).
Finding:
On 10/18/23, Resident #1''s clinical record was reviewed indicating the resident was originally admitted to the facility on [DATE] with multiple mental health diagnoses as well as Post Traumatic Stress Disorder (PTSD).
The Minimum Data Set (MDS) Quartely 3.0, dated 8/15/23, indicated, under Active Diagnosis Section I6100, that the resident had PTSD.
On 10/18/23 at 10:30 a.m., during an interview with a surveyor, the Bayview Social Worker (BSW) stated that Social Services was responsible to complete the trauma screen on admission and to complete the care plan. The surveyor explained that she was unable to determine what Resident #1's triggers might be based on this screen and review of the careplan. At 11:00 a.m., the BSW provided what information she had. The information provided was included on the Level II Preadmission Screening and Resident Review (PASRR) dated 6/29/22. BSW also stated that the facility's Social History Evaluation, dated 5/12/23, asked questions about if the resident experienced trauma or certain events that were answered with a yes or no response. but it did not ask the resident about what type of event may be a trigger to the past trauma. BSW stated she was unaware that this needed to be included in the evaluation and/or careplan but was able to discuss some of Resident #1's trust issues and feeling no one liked him/her which may have been related to the history of bullying. Upon review of the PASRR, there was some information about what symptoms, events, or behaviors may be triggers or exhibited by the resident. The BSW and surveyor reviewed Resident #1's care plan, and the surveyor confirmed that it was not revised to include trigger-specific interventions to decrease Resident #1's exposure to triggers which may re-traumatize the resident, as well as identify ways to mitigate or decrease the effect of the trigger on the resident. The interventions were not created related what information the facility was able to obtain and was not individualized for Resident #1.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Accident Prevention
(Tag F0689)
Could have caused harm · This affected 1 resident
Based on facility reported incident and investigation, record review, facility policy review, and interviews, the facility failed to supervise a resident safety and complete a new elopement risk evalu...
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Based on facility reported incident and investigation, record review, facility policy review, and interviews, the facility failed to supervise a resident safety and complete a new elopement risk evaluation/assessment after a resident received a new power wheelchair and expressed the desire to leave the facility and go to the store. This failure enabled the resident to leave the facility's grounds without staff knowledge or supervision and cross a 3 lane street for 1 of 1 incidents reviewed (10/5/23).
Findings:
Review of the facility's incident report sent to the State Agency on 10/6/23 indicated that Resident #1 was seen by staff across the street on 10/5/23 at 2:13 p.m. after being let outside by a staff member at 1:54 p.m. Staff immediately went to get the resident when he/she was noticed and the resident was returned to the facility with no injuries. The facility's investigation was completed on 10/11/23 and included written statements from staff. Certified Nursing Assistant - Medication (CNA-M) completed a written statement on 10/5/23 that indicated he had seen Resident #1 outside before in his/her old wheelchair and he was the one that let Resident #1 outside. He was unaware that Resident #1 could not go outside unsupervised. Another statement completed by Physical Therapy Assistant (PTA) on 10/7/23, indicated that on 9/29/23, Resident #1 was released from therapy with the new power wheelchair and that Resident #1 asked her about going across the street to the store with the new chair. PTA wrote that she educated Resident #1 that he/she could not leave the premises unsupervised in the power wheelchair.
On 10/18/23 at 9:15 a.m., during an interview with a surveyor, the Director of Nursing stated that PTA had not shared with nursing that Resident #1 had asked about leaving the premises with the new power wheelchair. Nursing was not aware that Resident #1 was keeping this power wheelchair either. It was confirmed that a new elopement risk assessment should have been completed on 9/29/23, after the statement of the desire to leave the grounds with the new power wheelchair which would have made Resident #1 an elopement risk.
On 10/18/23 at 9:40 a.m., during an interview with a surveyor, PTA stated that she did not tell anyone about Resident's #1 statement about wanting to leave the facility grounds (with the power wheel chair) but stated that she did educate the resident that he/she could not leave unsupervised. PTA did state that there was a Certified Nursing Assistant in the room when Resident #1 asked about going to the store with the power wheelchair.
On 10/18/23 at 10:30 a.m., during an interview with a surveyor, Resident #1 stated that he/she is now reminded every day that he/she cannot leave the grounds with the power wheelchair. Resident #1 stated that a couple of cars and a bus stopped so he/she could get across the street. Once across the street, Resident #1 stated he/she changed his/her mind and was coming back to the facility.
The facility's policy, Elopement, revised 2/23, indicated that Residents will be accounted for at all times and that a risk evaluation will be done on new admissions and with a change of resident's condition.
As a result of this isolated incident, the following corrective actions were initiated with a completion date of 10/16/23:
- A new elopement risk assessment was completed on 10/5/23. A wander guard/secure care was placed on Resident #1's power wheelchair.
- Resident #1's photo was added to the elopement book that is kept at the front desk of the lobby.
- Increased communication between therapy and nursing - educated Therapy Manager about need to communicate to nursing when there is an upgrade of equipment.
- Education to nursing that a new elopement risk assessment was to be completed when there is a change of mobility for a resident.
- Complete a new elopement risk assessment when a resident receives a new piece of equipment (used for mobility).
- During daily morning meetings ask if a resident has received a new piece of equipment.
- The facility will continue to conduct elopement drills.
Jun 2023
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Quality of Care
(Tag F0684)
Could have caused harm · This affected 1 resident
Based on record reviews and interviews, the facility failed to ensure that a resident received treatment and services in accordance with the standards of practice for 1 of 7 residents reviewed (Reside...
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Based on record reviews and interviews, the facility failed to ensure that a resident received treatment and services in accordance with the standards of practice for 1 of 7 residents reviewed (Resident #1).
Findings:
Resident #1 was admitted to Brewer Center for Health & Rehabilitation Center (BCHR) on 4/8/23 with diagnoses to include neuromuscular dysfunction of bladder, anoxic brain damage, muscle weakness, cognitive communication deficit, dysphagia, abnormalities of gait and mobility, aphasia, anxiety disorder, encephalopathy, gastrointestinal hemorrhage, ileostomy, gastrostomy, essential hypertension, hyperlipidemia, unsteadiness on feet, and chronic embolism and thrombosis of unspecified deep veins of right lower extremity.
On 4/8/23 Hospital discharge documentation stated, follow-up appointments: .recommend urology follow up as an outpatient for void trial and foley removal if needed.
On 4/18/23 facility provider progress note signed by the Adult Gerontology Nurse Practitioner, Certified (AGNP-C) stated, Nursing reporting patient still with slight hematuria did discuss this has been ongoing with plan to follow up with urology., and continue with foley and follow up with urology.
On 4/18/23 facility provider order, signed by AGNP-C stated, He/she had hematuria on admission it has been ongoing and has referral for urology.
On 6/5/23 at 12:08 p.m. facility provider progress note, signed by AGNP-C, stated, It was recommended for him/her to follow-up with urology. Continue with Foley due to neurogenic bladder, would suggest voiding trials be done in urology office.
On 6/7/23 at 11:56 a.m. in an interview with the Administrator, a surveyor confirmed that Resident #1's clinical record lacked evidence that a referral was made to urology.
Mar 2023
1 deficiency
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Facility Reported Incident report, facility's investigation, facility's Fall Prevention Program, record r...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the Facility Reported Incident report, facility's investigation, facility's Fall Prevention Program, record review (care plan and [NAME]), and interviews, the facility failed to ensure that care plan interventions for the use of a gait belt during transfers were followed for 1 of 3 sampled residents (#1). This failure to use a Gait Belt resulted in Resident #1 falling and sustaining a distal femur fracture.
Finding:
During a review of the Facility's Reported Incident form, the report indicated that on 2/3/23 at 3:00 p.m., [Resident #1] was being transferred from his/her wheelchair back into bed with the assistance of a Certified Nursing Assistance (CNA). During this transfer the CNA did not use a gait belt during the transfer. During this transfer Resident #1's legs buckled, and the CNA and [Resident #1] fell on the floor twisting [Resident #1's] left leg resulting in an instant pain that was later identified as a distal femoral fracture.
On 3/7/23 at 3:49 p.m., during an interview with the involved CNA, the CNA stated she was transferring [Resident #1] from his/her wheelchair back into their bed. During this transfer resident's bottom half (legs) gave out causing him/her to step back and fall to the floor. The CNA stated she did not use a gait belt because she thought since she had done this transfer so many times that she didn't need to use it.
On 3/7/23 Resident #1's care plan, with a revision date of 12/15/21, under the Focus area of Activities of Daily Living (ADL) self-performance deficit, contained an intervention that directed staff that Resident #1 was an extensive assist by 1 staff to move between surfaces using a gait belt and verbal cueing to resident when transferring.
On 3/7/23 during a review of resident [NAME] under Transferring section, directs staff transfers are done with extensive assist by 1 staff to move between surfaces using gait belt and verbal cueing to resident when transferring.
Review of the facility's Fall Prevention Program with a revision date of 9/2017 directs staff on page 2 to develop interventions and incorporate them into the resident care plan and on page 3 the program directs staff to follow directions for care as indicated on the resident care flow sheets. ([NAME])
On 3/7/23 at 2:02 p.m. the surveyor discussed and confirmed with the Administrator that the CNA did not use the gait belt during this transfer that resulted in a distal femur fracture. At this time the Administrator notified the surveyor that the facility had identified and acted upon this finding on the day after the fall to prevent future occurrences. See list below for actions facility initiated.
As a result of the facility's investigation, the following corrective actions were initiated on 2/3/23:
- Resident was assessed immediately by Nursing.
- Order for an x-ray was obtained on 2/3/23
- X-ray completed on 2/4/23.
- Resident was sent out on 2/4/23 for treatment and evaluation.
- Resident care plan was reviewed for how to transfer resident and the facility
- 2/3/23 Unit Manager contacted the involved CNA and identified the transfer was done without the use of a gait belt.
- CNA was informed of the need to complete an on-the-job education regarding proper transfers following interventions listed on residents care plan.
- All care plans were audited to ensure accuracy for transfer methods were listed on CNA [NAME]
- Regional Clinical Support person contacted
- Wrote a root cause analysis
- Wrote a plan of action for this event
- Created audits for monitoring transfers being completed per care plans
- Unit manager completed an audit to ensure all residents who require a gait belt for transfers had a gait belt available in their rooms.
- On 2/5/23, started to provide education to those who were in the building.
- On 2/6/23, reviewed new POC and KPI developed over the weekend as a response to the fall with fractures with Leadership team and logged as an interim QAPI.
- Nurse assigned to complete education with the nursing team. Added in this education was fall prevention policy, accident/incident policy and procedure, no lift acknowledgement, and how to access the [NAME]. Training was completed from 2/4/23 until 2/1523.
- Audits have been done weekly since fall.
Feb 2023
1 deficiency
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to ensure that clinical records were complete and contained accurate i...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview the facility failed to ensure that clinical records were complete and contained accurate information for 3 of 3 sampled residents reviewed for Treatment Administration (Resident's #1, #2 and #3).
Findings:
1. Resident # 1 was admitted to facility on 10/25/18 with diagnoses to include, obstructive sleep apnea, respiratory failure with hypoxia, edema, and severe morbid obesity.
Review of Resident #1's signed provider orders dated 2/1/23 revealed the following.
-Order with start date of 1/25/23 for Cleanse areas to bilateral posterior thighs with NS [normal saline], pat dry, apply Mepilex every day shift every 3 day(s) for protection. Review of Resident #1's February (Feb) 2023 (23) Treatment Administration Record (TAR) lacked evidence this was completed or refused on 2/6/23 during the 7A-7P shift.
-Order with a start date of 12/10/220 to Clean buttocks well QAM and pat dry. Apply barrier cream to buttock BID every day and evening shift for wound care. Review of Resident #1's [DATE] TAR lacked evidence this was completed or refused on 2/18/23 on 3P-11P shift.
-Order with start date of 2/9/23 for Lortisone Cream 1-0.05% (Clortimazole-Betamethasone). Apply to any red/open area topically every day and evening shift for Red/open areas for 14 days apply to any red/open areas in abd/back/groin/thigh folds. Review of Resident #1's [DATE] TAR lacked evidence this was completed or refused during the 3p-11p shift on 2/14/23, 2/16/23, 2/18/23 or 2/19/23.
-Order with start date of 2/1/23 for oxygen @1-2 liters to maintain sats 89-92% every shift for maintain sats. Review of Resident #1's [DATE] TAR lacked evidence this was completed or refused on 2/17/23 on the 10p-6am shift.
During an interview on 2/22/23 at 9:30 a.m., Resident #1 indicated that she has not refused any treatments and knows that his/her skin care is important.
2. Resident #2 was admitted to facility for rehabilitation services on 1/12/23 with diagnoses to include lumbar fracture, Unitary tract infection, chronic heart failure, and dementia. Resident #2 was discharged on 2/10/23.
Review of admission Minimum Data Set (MDS) dated [DATE] revealed Resident #2 had a Brief Interview for Mental Status of 4 of 15 indicating he/she was not cognitively intact. Further review of MDS revealed that Resident #2 was dependent on staff for Activities of Daily Living needs during his/her stay.
Review of Resident #2's most recent provider orders signed 2/2/23 revealed:
-Order with start date of 1/26/23 to Daily pulse OX [oximeter] one time a day for MD order. Review of Resident #2's [DATE] TAR lacked evidence this was completed or refused on 2/6/23 at 0900.
-Order with start date of 1/26/23 to Ensure that resident's hair is combed every morning, one time a day per Family request. Review of Resident #2's [DATE] TAR lacked evidence this was done or refused on 2/6/23.
-Order with start date of 1/18/23 If resident develops NA (nausea)/pain [sent] to ED (emergency department) every shift. Review of Resident #2's February TAR lacked evidence this was assessed on 2/6/23 during the 7a-3p shift.
-Order with start date of 1/12/23 for Dulcolax Suppository 10 mg (Biscodyl) Insert 1 suppository rectally as needed for constipation x 1 dose if MOM [Milk of Magnesia] ineffective. Review of [DATE] TAR revealed administered on 2/2/23 and 2/10/23
-Order with start date of 1/13/23 Diet recommendations provide pt with drinks and check for pocketing.
Review of Resident #2's Care Plan initiated on revealed The resident has an ADL [activities of daily living] self-care performance deficit .Eating: Supervision with meals
Review of Resident #2's clinical record under Task: Eating Self Performance- How the resident eats and drinks, regardless of skill revealed: Independent-NO help or staff oversight at any time on 1/23/23 at 10:18 and 12:00, 1/25/23 at 12:37, 1/26/23 at 13:12 and 16:59, 1/27/23 at 18:41, 1/29/23 at 12:00, 1/31/23 at 16:09, 1/31/23 at 09:48, 2/1/23 at 17:39, 2/2/23 at 21:07, 2/4/23 at 09:00 and 12:49, 2/5/23 at 16:10, 2/6/23 at 13:57, and 21:08, 2/7/23 at 14:18 and 17:15, 2/8/23 at 12:42.
During an interview on 2/22/23 at 3:12 p.m., Certified Nursing Assistant (CNA1) indicated that if a resident's care plan says that they need to be supervised when eating, then that means that someone has to be in an area that they can see them to keep an eye on them in case they choke. CNA1 further indicated that independent means absolutely no help at all, and no supervision and supervision means they are keeping an eye on them.
3. Resident #3 was admitted to facility on 4/4/18 with diagnoses to include, chronic pain, intervertebral disc disorder, kidney stones, and acute kidney failure.
Review of Resident #3's most recently signed provider orders dated 2/14/23 revealed the following:
-Order with start date of 1/27/23 for Voltaren Gel 1% (Diclofenac Sodium) Apply to Neck and right shoulder topically one time a day for Pain. Apply 2 grams. Review of Resident #3's February (Feb) 2023 (23) Treatment Administration Record (TAR) lacked evidence this was administered or refused on 2/16/23.
-Order with start date of 1/27/23 for Voltaren Gel 1% (Diclofenac Sodium) Apply to left heel/foot topically every shift for pain 2 grams.: Review of Resident #3's [DATE] TAR lacked evidence this was administered or refused on 2/16/23 or 2/17/23 on the 7A-7P shift.
-Order with start date of 1/27/23 to Flush foley BID [twice daily] with 60 ml of NaCl two times a day for prophylaxis. Review of Resident #3's [DATE] TAR lacked evidence this was administered or refused on 2/16/23 at 0800.
During an interview on 2/22/23 at 10:15 a.m. Licensed Practical Nurse (LPN)1 indicated that all treatments are to be administered as ordered and documented in the Electronic Medical Record (EMR) as they are done and if they are refused it should indicate the refusal. LPN1 further indicated that if a resident needs supervision when eating then staff are supposed to keep an eye on them during all meals and it needs to be documented as Supervision In the EMR.
During an interview on 2/22/23 at 3:30 p.m., the Assistant Director of Nursing (ADON) confirmed the above missing documentation.
During an interview on 2/22/23 at 3:55 p.m., the above was discussed with the Administrator.
Dec 2022
3 deficiencies
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Report Alleged Abuse
(Tag F0609)
Could have caused harm · This affected 1 resident
Based on interviews, and record review the facility failed to notify the State Agency in a timely manner after it was brought to their attention that multiple residents on the B wind did not receive t...
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Based on interviews, and record review the facility failed to notify the State Agency in a timely manner after it was brought to their attention that multiple residents on the B wind did not receive their evening meal on 11/30/22. This had the ability to affect all 43 residents on the B wing.
Findings:
On 12/15/22 the Department of Licensing & Certification received an anonymous call indicating that 21 residents did not receive their evening meal on 11/30/22.
During an interview on 12/28/22 at 9:19 a.m., Dietary Manger (DM) indicated a few trays did not get passed a few weeks ago. DM further indicated that on 11/30/22 the night dietary staff noticed a lot of trays not getting touched. When asked how many trays, DM indicated 15 or so, then indicated they have some on hospice residents, and some don't eat regularly but she was unable to give the exact number of untouched trays.
During an interview on 12/28/22 at 10:45 a.m., Dietary Aide (DA) indicated that she was working in the dish room stripping trays on 11/30/22 during the evening meal and noticed an overwhelming number of trays that were untouched. When asked if the side cups of deserts, or fruit cups were eaten? she replied, not a thing on the trays was touched, at all. DA then indicated this was concerning to her because they normally will see some trays that get returned, but it was the large number of trays that she noticed that was so concerning. DA stated she did not count or save the meal tags, and some meal tags were missing and she not have an exact amount, but it was definitely more than 15. DA then indicated that she reported the information to the Dietary Manager either that evening or the next morning.
During an interview on 12/28/22 at approximately 2:45 p.m., the Administrator indicated during morning meeting on 12/1/22 she was notified that a large number of food trays were returned to dietary the night before and she did not report it to licensing because she did not have any resident or family complaints.
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Investigate Abuse
(Tag F0610)
Could have caused harm · This affected 1 resident
Based on interviews and record review and facility policy, the facility failed to thoroughly investigate an incident when it was reported by dietary staff that, multiple residents did not receive/eat ...
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Based on interviews and record review and facility policy, the facility failed to thoroughly investigate an incident when it was reported by dietary staff that, multiple residents did not receive/eat their evening meal on 11/30/22. This had the potential to affect all 43 residents on the B wing.
Findings:
On 12/15/22 the Department of Licensing & Certification received an anonymous call indicating that 21 residents did not receive their evening meal on 11/30/22.
During an interview on 12/28/22 at 9:19 a.m., Dietary Manger (DM) indicated that a few trays did not get passed a weeks ago. DM further indicated that it was reported to her by dietary staff the next morning that 15 or so trays didn't get touched. When further questioned, DM indicated that she was not aware of the exact number of untouched trays as they did not save the residents tray tags, and did not write down the names, but residents were offered alternatives and they were refused.
During an interview on 12/28/22 at 9:22 a.m., the Director of Nursing (DNS) indicated that on 11/30/22 a large number of meal trays did not get served during the evening meal and they were unable to determine how many. DNS then indicated that the Unit Manger was doing the investigation.
During an interview on 12/28/22 at 10:05 a.m., Staff #2 indicated that a couple of weeks ago they had a meeting because a lot of trays weren't passed at a dinner service. When asked how many trays weren't passed, Staff #2 indicated they weren't positive but in the 20 range.
During an interview on 12/28/22 at 10:18 a.m., Social Worker (SW) indicated that she heard in morning meeting on 12/1/22 that 21 trays were returned to the kitchen untouched, is not sure what was implemented because the Unit Manager is taking care of it but does know some education was put into place.
During an interview on 12/28/22 at 10:45 a.m., Dietary Aide (DA) indicated that on 11/30/22 while stripping meal trays she noticed an overwhelming number of trays that were untouched. When asked if the side cups of deserts, or fruit missing? she replied, not a thing on the trays was touched, at all. DA then indicated this was concerning to her because they normally will see some trays that get returned, but it was the large number of trays that she noticed that was so concerning so she asked the other dietary staff if anyone from B wing ordered an alternative meal and was able to confirm that no one had. DA stated she did not count or save the meal tags, and some were missing and did not have an exact amount, but it was definitely more than 15. DA then indicated that she reported the information to the Dietary Manager either that evening or the next morning.
During an interview on 12/28/22 at 10:51 a.m., Dietitian indicated on 12/1/22 she was made aware that a large number of trays were returned untouched form the B wing but does not know the exact number and does not know who didn't get a meal, but it was a very large amount. At this time Dietitian confirmed that no one from dietary went around to resident rooms to ask if they had received the evening meal but she believed that the facility was completing an investigation as to what had happened and is not part of it.
During an interview on 12/28/22 at 11:45 a.m., B Wing Unit Manager (UM) indicated that during morning meeting on 12/1/22 she was made aware that a large number of residents did not receive a meal tray the night before on 11/30/22. UM indicated that she spoke with the staff that worked that evening, but she did not document anything, and did not think to interview any residents but there were approximately 51 residents on the B wing during that time. When asked, UM confirmed that that she did not review any clinical records for meal intakes that evening or interview any residents', to see if they ate, but she probably should have. At this time UM confirmed that a complete investigation was not done.
During an interview on 12/28 22 at 1:30 p.m., Resident #10 indicated [he/she] is an [old man/woman] and does not like to complain about anything and [he/she] tries to take things as they come and may not make a big deal out of it but does remember not getting a meal and calling [his/her] spouse to say he/she didn't get any food. Review of Resident #10's Basic Interview for Mental Status (BIMS) dated 10/9/22 revealed a score of 15 of 15 indicating [he/she] is cognitively intact.
During an interview on 12/28/22 at 1:35 p.m., Resident #10's spouse indicated that [he/she] distinctly remembers getting the phone call around 7:30 p.m. on 11/30/22, and [he/she] said that [he/she] did not get any food and [he/she] was hungry. Spouse further indicated that she did not call the nurses station at that point in time because [he/she] thought that someone would have gone around and made sure they ate or were given a snack or something. Spouse then stated that [he/she] came in the next morning, and no one was ever able to tell [him/her] if [Resident #10] ever got any food the night before or not. Spouse indicated that [he/she] did not file a grievance with the facility as it would do no good.
During an anonymous interview on 12/28/22, Anonymous staff member #1 indicated that on 12/1/22 they were informed that 21 patients on the long-term care unit on B wing did not get a meal tray the evening before and a family member called and complained that their spouse didn't get any dinner.
During an anonymous interview on 12/28/22, Anonymous staff member#2 indicated that they were made aware that on 11/30/22 that 21 residents did not get food trays during the dinner meal on B wing and that there was camera footage that a CNA [Certified Nursing Assistant] pulled out dietary slips and wrote refused on them and put them back in the meal cart.
During an interview on 12/28/22 at approximately 2:45 p.m., Administrator indicated that on 12/1/22 during morning meeting, she was made aware that that a large number of food trays were returned to dietary the night before on 11/30/22 and did not investigate it because she did not have any complaints about residents not eating. When asked why an investigation was not done, due to the large number of returned trays, and at that point in time to rule out any other concerning issues. Administrator indicated a lot of times a resident will not touch the food, but they'll eat the pudding that is in the cup on the side or the fruit that is in the cup on the side or just take the coffee, but they were unsure of what was eaten, and they didn't keep the slips they have no idea what residents they were. At this time Administrator confirmed that a complete investigation was not done.
CONCERN
(E)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0692
(Tag F0692)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to consistently monitor meal intakes for 5 of 12 Residents. (Residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews, and record review, the facility failed to consistently monitor meal intakes for 5 of 12 Residents. (Resident's #3, #5, #7, #9 and #10).
Findings:
On 12/15/22 the Department of Licensing & Certification received an anonymous complaint that 21 residents were not served an evening meal on 11/30/22. The following is a result of this investigation:
1. Resident #3 was admitted to the facility on [DATE] with diagnoses to include dementia and dysphagia.
Review of Resident #3's nutrition evaluation dated 11/18/22 indicated Resident #3 is a nutrition risk due to inadequate food intake.
Review of quarterly Minimum Data Set (MDS) dated [DATE] indicated Resident #3 had a Brief Interview for Mental Status (BIMS) of 0 of 15 indicating that [he/she] was not cognitively intact and was dependent on facility staff to meet [his/her] needs.
Review of Resident #3's care plan revealed nutrition intervention implemented on 3/4/22 most recently revised stating: The resident will maintain adequate nutritional status as evidenced by maintaining weight , consuming at least 50% of at least 2 meals daily through review date Monitor intake and record q meal.
Review of Resident #3's entire clinical record revealed the following meal intakes between 11/29/22 and 12/28/22 (30 days).
-No evidence to indicate if Resident #3 was offered or refused am meal recorded on 11/29/22, 11/30/22, 12/1/22, 12/7/22, 12/10/22, 12/11/22, 12/12/22, 12/14/22, 12/16/22, 12/17/22, 12/24/22, 12/25/22 or12/27/22.
-No evidence to indicate if Resident #3 was offered or refused the noon meal on 11/30/22, 12/7/22, 12/9/22, 12/11/22, 12/17/22, or 12/28/22.
-No evidence to indicate of Resident #3 was offered or refused the evening meal on 12/5/22, 12/8/22, 12/11/22, 12/19/22, 12/22/22, 12/27/22 or 12/28/22.
2. Resident #5 was admitted to facility on 2/22/19 with diagnoses to include paranoid schizophrenia, manic depression and morbid obesity and was opened to hospice on 11/28/22.
Review of quarterly MDS dated [DATE] revealed Resident #5 had a BIMS of 13 of 15 indicating he/she was cognitively intact and was dependent of staff to set up for meals.
Review of Resident #5's care plan initiated on 2/22/19 revealed the following:
-Nutrition concern updated:11/25/2022- [Resident #5] has actual nutritional problem r/t morbid obesity, variable PO intake, mech altered texture w/ dysphagia .Hospice. Resident's medical, dietary, spiritual, and psychological needs will be met through collaborative efforts of both SNF and Hospice Staff through the review period. Provide, serve diet as ordered. Monitor intake and record q meal.
Review of Resident #5's entire clinical record revealed the following meal intakes from 11/28/22 through 12/28/22 (30 days):
-No evidence to indicate Resident #5 was offered or refused am meal on 11/29/22, 12/2/22, 12/8/22, 12/9/22, 12/12/22, 12/15/22, 12/16/22, 12/17/22, 12/19/22, 12/26/22 or 12/28/22.
-No evidence to indicate Resident #5 was offered or refuses noon meal on 11/29/22, 12/2/22, 12/8/22, 12/9/22, 12/10/22, 12/12/22, 12/13/22, 12/14/22, 12/17/22, 12/22/22, 12/23/22, or 12/26/22.
-No evidence to indicate Resident #5 was offered or refused evening meal on 11/30/22, 12/3/22, 12/9/22, 12/10/22, 12/11/22, 12/12/22, 12/18/22, 12/21/22, 12/23/22, or 12/28/22.
3. Resident #7 was admitted to the facility on [DATE] with diagnoses to include Alzheimer's disease, dementia, and malnutrition.
Review of quarterly MDS dated [DATE] BIMS of 0 of 15 indicating significant cognitive impairment. Further review indicated that Resident #7 was dependent on staff for all his/her needs.
Review of Resident #7's care plan initiated on 7/2/20 revealed the following:
- Nutrition concern dated 6/2/21 states: [Resident #7] has actual nutritional problem: Risk for [wt] loss d/t disease process: dementia . no s/sx of malnutrition and consuming at least 50% of at least 2 meals daily. report PRN any Refusing to eat. Provide, serve diet as ordered. Monitor intake and record q meal.
Review of Resident #7's entire clinical record reveled the following meal intakes from 11/29/22 through 12/11/22.
-No evidence Resident #7 was offered or refused am meal on 11/29/22, 11/30/33, 12/3/22, 12/5/22, or 12/7/22.
4. Resident #9 was admitted to the facility on [DATE] with diagnoses to include dementia and malnutrition.
Review of Resident #9's Minimum Data Set, dated [DATE] revealed BIMS of 9 of 15 indicating moderate cognitive impairment.
Review of Resident #9's care plan initiated on 4/12/22 revealed the following:
-Nutrition concern dated 4/18/22 states: [Resident #9] has actual nutritional problem d/t severe PCM, [h/o] [wt] loss. Risk for [wt] loss d/t disease process: dementia. The resident will maintain adequate nutritional status as evidenced by .consuming at least 50% of at least 2 meals daily through review date. Monitor/report .Refusing to eat.
Review of Resident #9's entire clinical record revealed the following meal intakes from 11/29/22 through 12/28/22 (30 days):
-No evidence Resident #9 was offered or refused the am meal on 11/29/22, 11/30/33, 12/3/22, 12/4/22, 12/9/22, 12/12/22, 12/18/22, 12/20/22, 12/21/22, 12/27/22, or 12/28/22.
-No evidence Resident #9 was offered or refused noon meal on 11/30/33, 12/2/22, 12/8/22, 12/9/22, 12/12/22, 12/13/22, 12/17/22, 12/18/22, 12/21/22, 12/26/22, or 12/27/22.
-No evidence Resident #9 was offered or refused evening meal on 11/29/22, 12/1/22, 12/6/22, 12/8/22, 12/20/22, 12/25/22, or 12/26/22.
5. Resident #10 was admitted to the facility on [DATE] with diagnoses to include paraplegia.
Review of quarterly Minimum Data Set (MDS) dated [DATE] indicates Resident #10 had a Brief Interview for Mental Status (BIMS) score of 15 of 15 indicating he/she is cognitively intact.
Review of Resident #10's care plan initiated on 12/31/22 revealed the following:
-Nutrition concern dated 1/5/22 states: [Resident #10] has actual nutritional problem: Altered nutritional needs, .Risk for PCM [patient care management] d/t poor PO [by mouth] intake.
-Nutrition concern dated 12/31/21 states: Resident goal: maintain current weight. Resident Goal: prevent weight loss. Monitor/report .Refusing to eat.
Review of Resident #10's entire clinical record revealed the following meal intakes from 11/29/22 through 12/28/22 (30 days):
-No evidence Resident #10 was offered or refused am meal on 11/30/22, 12/3/22, 12/5/22, 12/8/22, 12/9/22, 12/15/22, 12/16/22, 12/17/22, 12/19/22, 12/20/22, or 12/21/22.
-No evidence Resident #10 was offered or refused noon meal on 12/2/22, 12/5/22, 12/8/22, 12/9/22, 12/10/22, 12/13/22, or 12/17/22.
-No evidence Resident #10 was offered or refused evening meal on 11/29/22, 12/5/2/2, 12/8/22, 12/9/22, 12/13/22, 12/21/22, 12/23/22, 12/25/22 or 12/26/22.
During an interview on 11/30/33 at 10:51 a.m., Dietitian indicated that it was her expectation that all meal intakes and refusals are documented during the shift.
During an interview on12/28/22 at 11:45 a.m., B Wing Unit Manager indicated that all meal intakes are to be recorded in the point of care system as soon as possible and she should be reviewing them on a regular basis, but she is new to the position and has not been doing that.
During an interview on 12/28/22 at 9:22 a.m., the Director of Nursing Services indicated that meal intakes are recorded after the meal and the unit managers review them and they are discussed in morning meeting.
During an interview on 12/28/22 at 9:53 a.m., Staff #1 indicated that all residents reguardless of their status (unless nothig by mouth) should be offerered a meal, even those receiving hospice care and refusals shold be docuemtned.
During an interview on 12/28/22 at 12:40 p.m., Staff #6 indicated that all meals need to be offered to residents regardless of their status and if they refuse an alternative should be offered. If they also refuse the alternative, it should be documented in the record as refused.
During an interview on 12/28/22 at 2:50 p.m., the above was discussed with the Administrator.
Nov 2022
1 deficiency
CONCERN
(D)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Potential for Harm - no one hurt, but risky conditions existed
Medical Records
(Tag F0842)
Could have caused harm · This affected 1 resident
Deficiency Text Not Available
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Deficiency Text Not Available
Nov 2022
6 deficiencies
1 Harm
SERIOUS
(G)
📢 Someone Reported This
A family member, employee, or ombudsman was alarmed enough to file a formal complaint
Actual Harm - a resident was hurt due to facility failures
Accident Prevention
(Tag F0689)
A resident was harmed · This affected 1 resident
Based on record reviews and interviews the facility failed to follow patient lift Manufacturers User Manual while transferring a resident resulting in a resident fall, hitting head on the sink, and re...
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Based on record reviews and interviews the facility failed to follow patient lift Manufacturers User Manual while transferring a resident resulting in a resident fall, hitting head on the sink, and resulting in resident having increase anxiety with patient lift transfers for 1 of 2 residents reviewed for accidents. (Resident #24)
Finding:
On 10/24/22 the Department of Licensing and Certification received a Report a Medical Facility Incident form stating that on 10/21/22 while a resident was being transferred in a mechanical lift, the mechanical lift tipped while preparing to lower resident into the wheelchair. The lift tipped over and the aide tried to help brace the resident's fall. The resident fell to the floor and hit [his/her} head onto the sink
On 10/31/22 at 2:00 p.m. during an interview with Resident #24 he/she stated that he/she has heard the reason the lift tipped over was because the staff did not have the legs completely opened. During the fall he/she hit his/her head on the sink. Resident #24 stated that he/she does not want to use the patient lift for his/her transfers, he/she is anxious about falling again but stated the facility is using more staff during the transfers and that makes him/her feel better about the transfer with the patient lift.
During review of the facility's investigation and written statements from the CNA's involved, the investigation documented that the legs/base of the patient lift was not opened for optimum stability and safety and the patient lift tipped with the resident still attached in the lift sling.
The written statement of a CNA involved acknowledges the legs of the patient lift were not in the open position and the left tipped over with the resident falling to the floor and hitting his/her head on the sink
On 11/2/22 at 6:16 p.m. during an interview with one of the CNA's involved, she stated that she was under the impression the legs on the patient lift were not to be opened until you moved forward towards the wheelchair. She also stated the other CNA's have been doing the same thing as well and that was how she was trained when she started to work the floor in December of 2021.
User Manual instructions for Invacare Reliant 600 Battery powered patient lift Warning; the legs of the lift must be in the maximum open position and the shifter handle locked in place for optimum stability and safety. If it is necessary to close the legs of the lift to maneuver the lift under a bed, close the legs of the lift only as long as it takes to position the lift over the patient and lift the patient off the surface of the bed. When the legs of the lift are no longer under the bed return the legs of the lift to the maximum open position and lock the shifter handle immediately.
On 11/2/22 during a record review, Social Worker Notes dated 10/27/22, stated Social Worker (SW) spoke with resident to follow up on last week's fall. Resident shared that he/she has had some increased anxiety since fall last week; resident reports experiencing some feelings of panic and tearfulness at times. Social Services note dated 10/29/22, Summary of psychosocial from fall to present day: Resident overall physically feels ok, states head is tender, and body is sore but healing. Emotionally and mentally having some increased anxiety surrounding transfers but feels with the support of the extra staff member during patient transfers it will be comforting.
On 11/2/22 at 2:13 p.m., the surveyor confirmed during an interview with the Director of Nursing that staff did not have the legs/base of the patient lift open for stability which resulted in the patient lift tipping and the resident falling to the floor and hitting his/her head on the sink.
As a result of the facility's investigation, the following corrective actions were initiated:
- Removed the 2 staff people from the floor and education was provided before returning to floor;
- Resident was assessed immediately by Medical Provider and sent to Emergency Room;
- Lift was removed and inspected;
- Neuro checks were completed, as ordered;
- Education was provided to staff on 10/21/22 by Staff Development Coordinator including policy review, competency completion and review of lift manual;
- Competency for the two CNA's was completed on 10/28/22;
- On 10/26/22 residents care plan was reviewed and updated.
-Therapy is working with resident to return to stand pivot transfer and decrease dependence on mechanical lifts; and
- An Annual Performance Improvement Plan was created and approved by regional on 10/27/22.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Resident Rights
(Tag F0550)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview's, the facility failed to promote care for a resident in a manner that maintained the residen...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview's, the facility failed to promote care for a resident in a manner that maintained the resident's dignity and/or respect when staff failed to properly dress a resident on 1 of 4 days of survey (11/3/22) (Resident #90).
Findings:
Resident #90 was admitted to the facility on [DATE] with diagnoses to include aphasia (loss of ability to understand or express speech), and hemiplegia (paralysis on one side of body).
On 11/3/22 at approximately 8:44 a.m., Resident #90 was observed being transported outside via wheelchair wearing a short sleeved shirt with no outerwear. In an interview with a surveyor, the Charge Nurse for Resident #90 stated that he/she should have clothing on to protect the resident from the cold and went to Resident #90's room and obtained a thick sweater.
On 11/3/22 at 8:45 a.m., Resident #90 was observed in a van getting ready for transport to an orthopedic appointment. The back doors of the van and the tail gait of the van were open. A transporter was assisting the resident. A surveyor and the Charge Nurse observed goose bumps on Resident #90's arms. When the Charge Nurse assisted in putting the sweater on the resident. The resident closed the front of the sweater tightly.
On 11/3/22 at 9:22 a.m. the temperature outside was 37 degrees Fahrenheit, and there was frost observed on the roof of the facility building.
On 11/3/22 at 9:37 a.m. during an interview with the Director of Nursing (DON), a surveyor confirmed that Resident #90 was not dressed appropriately for the weather outside. The DON stated that the resident should have had on warm clothing.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0561
(Tag F0561)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a resident's choice in the area of bathing was being f...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a resident's choice in the area of bathing was being followed for 1 of 7 residents interviewed that resided on A wing (Resident #22).
Finding:
On 10/31/22 at 12:18 p.m., during an interview with a surveyor, Resident #22 stated that he/she has received about 5 showers (since been admitted ). The resident stated that he/she received a shower last week but not the week before.
On 10/31/22, the surveyor reviewed the Certified Nursing Assistant (CNA) tasks for Resident #22 that indicated Resident #22 was to receive a shower on Monday - day shift.
On 11/2/22 at 12:57 p.m., during an interview with a surveyor, CNA #5 stated that the shower schedule is in a book and upon review, stated that Resident #22 was scheduled to receive a shower on Mondays - evening shift. CNA #5 also stated that Resident #22 required supervision when taking a shower.
On 11/2/22 at 1:44 p.m., during an interview with a surveyor, Resident #22 denied ever refusing to take a shower. At 1:54 p.m., CNA #6 stated that she has never given Resident #22 a shower and that the resident never refused an offer of a shower and indicated that the resident would need set up assistance. CNA #6 also stated that Resident #22 is pretty independent but there was a little span that he did require more help. At 2:16 p.m., during an interview with a surveyor, CNA #5 stated that she has given the resident 1 shower and that he/she has never refused an offer of a shower. At 2:20 p.m., during an interview with a surveyor, CNA #7 stated that Resident #22 is independent for bathing and showering and that we just have to get the resident things like towels or pass things to him/her but the resident can wash him/herself. CNA #7 stated that Resident #22 has never refused a shower for her.
On 11/2/22, a review of 3 months of shower documentation for Resident #22 indicated: August received a shower 2 out of 5 Mondays, September received a shower 0 out of 4 Mondays with one of the above CNAs documenting that the Resident refused, and October received a shower 1 out of 5 Mondays. There were no other days of the week with a shower documented as being given.
On 11/2/22 at 2:42 p.m., during an interview with the Director of Nursing, the surveyor reviewed resident's bathing documentation. The surveyor explained that the bathing schedule shows evening shift on Mondays and the [NAME] (CNA electronic tasks) shows day shift on Mondays and that interviews with 3 CNAs (out of 5) that have documented in Resident #22's clinical record on whether or not Resident #22 received a shower for the months of August - October all stated that the resident has never refused a shower as well as the resident stated the same. The surveyor confirmed Resident #22 was not receiving showers.
CONCERN
(D)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0655
(Tag F0655)
Could have caused harm · This affected 1 resident
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a resident was involved in the development of the resi...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to ensure that a resident was involved in the development of the resident's baseline care plan and was provided a summary of the care plan for 1 of 4 residents reviewed for baseline care plans (Resident #22).
Finding:
On 10/31/22 at 12:27 p.m., during an interview with a surveyor, Resident #22 stated that he/she did not know what a care plan was and that he/she had never been invited to a meeting (Resident was admitted [DATE]).
On 11/3/22, Resident #22's clinical record was reviewed and the surveyor could not find evidence of a baseline care plan being provided to the resident. At 8:54 a.m., the surveyor asked the Licensed Social Worker (LSW) for A Wing if Resident #22 had received a copy of his/her baseline care plan because the surveyor could not find the signed document uploaded like the other residents. At 10:27 a.m., during an interview with a surveyor, the LSW for A Wing stated that he could not find evidence that Resident #22 was provided a copy of the baseline care plan and stated, somehow we missed [resident]. The surveyor confirmed the resident did not receive a written copy of the baseline care plan.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Safe Environment
(Tag F0584)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/31/22 during lunch meal observation in the B unit dining room the residents were served their lunch meal on a meal tray.
O...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** On 10/31/22 during lunch meal observation in the B unit dining room the residents were served their lunch meal on a meal tray.
On 11/1/22 during meal observations in the B unit dining room it was observed that the residents were served their breakfast and lunches on meal trays.
On 11/2/22 during meal observations in the B unit dining room it was observed that the residents were served their breakfast and lunches on meal trays.
On 11/3/22 during a breakfast meal observation it was observed that the residents in the B unit dining room were served their breakfast on a meal tray.
On 11/3/22 at 8:15 a.m. surveyor confirmed with staff in the B unit dining room that the residents meals were served on meal trays. Staff stated that meals were served on trays to allow for easy clean up after the meal service and they were not aware meals shouldn't be served on trays.
Based on observations and interview, the facility failed to ensure a wainscoting molding, resident window blinds, and a room divider curtain were in good repair 1 of 1 environmental tour. In addition, the facility failed to create a homelike dining experience for residents dining in the B unit dining room by serving their breakfast and lunch meals on a tray. For 7 of 7 meals observed.
Findings:
On 11/3/22 at 11:00 a.m., the surveyor, Administrator, Maintenance Supervisor conducted an environmental tour on B-Unit. The following observations were confirmed at the time of observation:
room [ROOM NUMBER]: Wainscoting molding separated from wall.
room [ROOM NUMBER]: The window blind slats were bent and broken.
room [ROOM NUMBER]: The window blind slats were bent and broken.
room [ROOM NUMBER]: The window blind slats were bent and broken.
room [ROOM NUMBER]: The room divider curtain soiled with a dry brown colored liquid stain.
CONCERN
(E)
Potential for Harm - no one hurt, but risky conditions existed
Deficiency F0657
(Tag F0657)
Could have caused harm · This affected multiple residents
**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/31/22 at 12:27 p.m., during an interview with a surveyor, Resident #22 stated that he/she did not know what a care plan...
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**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2. On 10/31/22 at 12:27 p.m., during an interview with a surveyor, Resident #22 stated that he/she did not know what a care plan was and that he/she had never been invited to a care plan meeting (Resident was admitted [DATE]). On 11/2/22, the surveyor reviewed Resident #22's clinical record but was unable to find evidence that care plan meetings were held. The surveyor noted MDS 3.0 assessments, dated 2/22/22, 4/11/22, 7/12/22, and 10/12/22, but the surveyor was unable to find evidence that the resident, who was responsible for him/herself, was included in the care plan meetings.
On 11/2/22 at 12:13 p.m., during an interview with a Licensed Social Worker (LSW) for A Wing, the surveyor requested evidence of Resident #22 being invited to care conference/plan meetings. At 1:30 p.m., during an interview with a surveyor, the LSW for A Wing stated he was unable to find evidence that Resident #22 was invited to care plan meetings and it was an oversight. He stated that he just spoke with Resident #22 and the resident did not recall ever being invited to a care plan meeting nor having received a care plan.
Based on record reviews and interviews, the facility failed to review and revise the care plan by an interdisciplinary team (IDT), which included the participation of the resident and resident's representative, after each assessment, for 2 of 2 residents who were reviewed for care plan meetings. (Resident #60, Resident #22)
Findings:
1. On 11/1/22 during resident interview along with his/her representative, Resident # 60 stated that he/she was not invited to their care plan meetings. Upon review of Resident #60's clinical record, the surveyor noted Minimum Data Sets (MDS) 3.0 assessments dated 6/25/22, 9/25/22 and 10/19/22, the clinical record lacked evidence that the resident and resident representative were included in the care plan meetings.
On 11/3/22 at approximately 1:00 p.m. the surveyor confirmed with the Social Worker for the B unit that Resident #60 has not had any care plan meetings since his/her 3/9/22 meeting. Resident #60 is not currently on the schedule for a care plan meeting and that Resident #60 may have been overlooked for scheduling care plan meetings.
Understanding Severity Codes (click to expand)
Life-Threatening (Immediate Jeopardy)
J - Isolated
K - Pattern
L - Widespread
Actual Harm
G - Isolated
H - Pattern
I - Widespread
Potential for Harm
D - Isolated
E - Pattern
F - Widespread
No Harm (Minor)
A - Isolated
B - Pattern
C - Widespread
Questions to Ask on Your Visit
- "Can I speak with families of current residents?"
- "What's your RN coverage like on weekends and overnight?"
Our Honest Assessment
Strengths
- • Licensed and certified facility. Meets minimum state requirements.
Concerns
- • 37 deficiencies on record, including 2 serious (caused harm) violations. Ask about corrective actions taken.
- • Grade C (58/100). Below average facility with significant concerns.
Bottom line: Mixed indicators with Trust Score of 58/100. Visit in person and ask pointed questions.
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About This Facility
What is Brewer Center For Health & Rehabilitation, Llc's CMS Rating?
CMS assigns BREWER CENTER FOR HEALTH & REHABILITATION, LLC an overall rating of 4 out of 5 stars, which is considered above average nationally. Within Maine, this rating places the facility higher than 99% of the state's 100 nursing homes. This rating reflects solid performance across the metrics CMS uses to evaluate nursing home quality.
How is Brewer Center For Health & Rehabilitation, Llc Staffed?
CMS rates BREWER CENTER FOR HEALTH & REHABILITATION, LLC's staffing level at 5 out of 5 stars, which is much above average compared to other nursing homes. Staff turnover is 47%, compared to the Maine average of 46%.
What Have Inspectors Found at Brewer Center For Health & Rehabilitation, Llc?
State health inspectors documented 37 deficiencies at BREWER CENTER FOR HEALTH & REHABILITATION, LLC during 2022 to 2025. These included: 2 that caused actual resident harm, 34 with potential for harm, and 1 minor or isolated issues. Deficiencies causing actual harm indicate documented cases where residents experienced negative health consequences.
Who Owns and Operates Brewer Center For Health & Rehabilitation, Llc?
BREWER CENTER FOR HEALTH & REHABILITATION, LLC is owned by a for-profit company. For-profit facilities operate as businesses with obligations to shareholders or private owners. The facility is operated by NATIONAL HEALTH CARE ASSOCIATES, a chain that manages multiple nursing homes. With 111 certified beds and approximately 101 residents (about 91% occupancy), it is a mid-sized facility located in BREWER, Maine.
How Does Brewer Center For Health & Rehabilitation, Llc Compare to Other Maine Nursing Homes?
Compared to the 100 nursing homes in Maine, BREWER CENTER FOR HEALTH & REHABILITATION, LLC's overall rating (4 stars) is above the state average of 3.0, staff turnover (47%) is near the state average of 46%, and health inspection rating (3 stars) is at the national benchmark.
What Should Families Ask When Visiting Brewer Center For Health & Rehabilitation, Llc?
Based on this facility's data, families visiting should ask: "Can I visit during a mealtime to observe dining assistance and food quality?" "How do you handle medical emergencies, and what is your hospital transfer rate?" "Can I speak with family members of current residents about their experience?"
Is Brewer Center For Health & Rehabilitation, Llc Safe?
Based on CMS inspection data, BREWER CENTER FOR HEALTH & REHABILITATION, LLC has a clean safety record: no substantiated abuse findings (meaning no confirmed cases of resident harm), no Immediate Jeopardy citations (the most serious violation level indicating risk of serious injury or death), and is not on the Special Focus Facility watch list (a federal program monitoring the lowest-performing 1% of nursing homes). The facility has a 4-star overall rating and ranks #1 of 100 nursing homes in Maine. While no facility is perfect, families should still ask about staff-to-resident ratios and recent inspection results during their visit.
Do Nurses at Brewer Center For Health & Rehabilitation, Llc Stick Around?
BREWER CENTER FOR HEALTH & REHABILITATION, LLC has a staff turnover rate of 47%, which is about average for Maine nursing homes (state average: 46%). Moderate turnover is common in nursing homes, but families should still ask about staff tenure and how the facility maintains care continuity when employees leave.
Was Brewer Center For Health & Rehabilitation, Llc Ever Fined?
BREWER CENTER FOR HEALTH & REHABILITATION, LLC has been fined $8,648 across 1 penalty action. This is below the Maine average of $33,165. While any fine indicates a compliance issue, fines under $50,000 are relatively common and typically reflect isolated problems that were subsequently corrected. Families should ask what specific issues led to these fines and confirm they've been resolved.
Is Brewer Center For Health & Rehabilitation, Llc on Any Federal Watch List?
BREWER CENTER FOR HEALTH & REHABILITATION, LLC is not on any federal watch list. The most significant is the Special Focus Facility (SFF) program, which identifies the bottom 1% of nursing homes nationally based on persistent, serious quality problems. Not being on this list means the facility has avoided the pattern of deficiencies that triggers enhanced federal oversight. This is a positive indicator, though families should still review the facility's inspection history directly.