Brush Hill Care Center

In the surveyor’s words

From the most serious findings on record at Brush Hill Care Center, in the surveyor’s own words.

• Actual harm, isolatedF656Jul 17, 2023

  Based on observations, interviews, and record review, the facility failed to develop a care plan for one Resident (#141), and implement care plans for 6 Residents (#118, #23, #13, #142, #19 and #62), out of a sample of 40 residents. Specifically, the facility failed: 1. For Resident #141, to develop a care plan to address wandering behavior resulting in a resident-to-resident altercation where the Resident sustained a laceration and skin tears; 2. For Resident #118, to provide supervision with meals per the care plan; 3. For Resident #23, to ensure he/she wore a boot per the physician's orders; 4. For Resident #13, to implement a suicidal ideation care plan; 5. […]

• Actual harm, isolatedF686Jul 17, 2023

  Based on observation, record review, and staff interviews, the facility failed to: 1. Ensure that the wound physician's recommendations were addressed and transcribed timely and accurately resulting in a delay of treatment for a skin injury on left foot/heel. Subsequently, the wound deteriorated to a Stage IV pressure injury and required an Intravenous (IV) antibiotics for treatment for one Resident (#124); and 2. Follow the physician's orders for prevention of a pressure ulcer for one Resident (#24), out of a total sample of 40 residents. Findings include: 1. […]

• Actual harm, isolatedF689Jul 17, 2023

  Based on observations, record review, and interview, the facility failed to ensure that the resident environment remained free of accident hazards. Specifically, the facility failed: 1. For Resident #141, to provide adequate supervision and assistance with ambulation resulting in a fall with skin tears and a laceration following a resident-to-resident altercation; 2. For Resident #13, to ensure fall mats were in place, as ordered by the Physician and indicated in his/her plan of care; 3. For Resident #23, to ensure seizure pads were placed on the bed's interior side rail to protect Resident #23 during a seizure; 4. […]

• No harm, potential for more than minimal, widespreadF835Sep 25, 2024

  Based on observations and interviews, the facility failed to ensure it was administered in a manner that enabled it to use resources effectively to attain the highest practicable physical, mental, and psychosocial well-being of each resident. Specifically, the facility failed to effectively manage and utilize their administrative team and stay up to date with current Centers for Disease Control and Prevention (CDC), Centers for Medicare and Medicaid Services (CMS), and Massachusetts Department of Public Health (MDPH) guidance. […]

• No harm, potential for more than minimal, widespreadF838Sep 25, 2024

  Based on document review and interview, the facility failed to develop and implement their facility assessment (a document assessing the capability of the facility and its resources to provide both emergency and day to day care of the population the facility currently serves). Specifically, the facility failed to: 1. Ensure active involvement of all required members when conducting the facility assessment; and 2. Implement the identified competency-based training as indicated. Findings include: Review of the Centers for Medicare and Medicaid Services (CMS) guidance, dated 6/18/24, indicated but was not limited to: -In conducting the facility assessment, the facility must ensure active involvement of the following participants in the process: a. […]