Brewster Convalescent Center

In the surveyor’s words

From the most serious findings on record at Brewster Convalescent Center, in the surveyor’s own words.

• Actual harm, isolatedF684Aug 28, 2023

  Based on medical record review and interview, the facility failed to thoroughly assess and provide timely medical treatment to a resident with multiple fractures. This affected one resident (#31) of four residents reviewed for accidents. Actual harm occurred on 04/16/23 when Resident #31 fell , hitting her elbow on the shower chair and landing on her buttocks. At the time of the fall, Resident #31 complained of elbow pain and tailbone pain, however only the elbow pain was assessed, and physician notified resulting in the resident receiving an Xray of the shoulder and being diagnosed with a fractured humeral head on 04/17/23. […]

• Actual harm, isolatedF697Aug 28, 2023

  Based on observation, medical record review, orthopedic consult review, therapy note review, and interview, the facility failed to manage Resident #31's pain adequately and within a timely manner. This affected one resident (#31) of one resident reviewed for pain management. The facility census was 51. Actual harm occurred on 04/16/23 to Resident #31, who had sustained a fall with fractured left humeral head and sacrum, when staff failed to adequately address the resident's pain resulting in Resident #31 having a decline in her activities of daily living. […]

• Actual harm, isolatedF686Jul 26, 2021

  Based on observation, review of the medical record, interviews with staff, and review of the facility policy the facility failed to prevent the development of a pressure ulcer for Resident #28. Actual harm occurred when Resident #28 developed an avoidable, in house acquired, stage three (full thickness wound with fat and tissue exposed) pressure ulcer to the left outer ankle. This affected one (Resident #28) of three residents reviewed for pressure ulcers. The facility census was 42. Findings include: Review of the medical record revealed Resident #28 was admitted to the facility on [DATE] with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, widespreadF812Aug 28, 2023

  Based on observation, interview, and record review, the facility failed to ensure clean and sanitary kitchen area and ensure appropriate glove use by kitchen staff. This had the potential to affect all residents receiving meals from the facility kitchen. The facility identified one resident (#38) as not receiving meals from kitchen for Nothing by Mouth (NPO) status. The facility census was 51. Findings include: Observations on 08/21/23 from 9:06 A.M. to 9:23 A.M. revealed under dry storage room storage racks was darkened, sticky flooring and there was various food debris and plasticwares. The main food preparation area contained food preparation tables, racks for storing cookware, and equipment including steamtable, deep fryer, oven with range and flat grill top. […]

• No harm, potential for more than minimal, widespreadF851Aug 28, 2023

  Based on interview, record review, and review of PBJ (Payroll Based Journal) data report the facility failed to ensure accuracy of PBJ information. This had the potential to affect all 51 residents residing in the facility. Findings include: Review of the facility PBJ Staffing Data Report dated 01/01/23 through 03/31/23 revealed submitted weekend staffing data was excessively low. Review of the facility nursing schedules from 01/03/23 through 02/28/23 did not reveal documentation when nurses assigned to the Nursing Home area of the facility were also required to cover the Assisted Living area on night shift. Further review did not reveal nurses signed out from the Nursing Home when they needed to go to the Assisted Living area, and did not sign back in when they returned. […]