Care One at Brookline

In the surveyor’s words

From the most serious findings on record at Care One at Brookline, in the surveyor’s own words.

• Actual harm, isolatedF688Oct 12, 2022

  Based on observation, record review, and interview the facility failed to prevent a worsening contracture for 2 Residents (#58 and #38) out of a total sample of 36 residents. Findings include: 1. Resident #58 was admitted in August, 2020 with diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident #58's most recent Minimum Data Set (MDS) assessment dated [DATE], indicated Resident #58 scored a 3 out of 15 on the Brief Interview for Mental Status (BIMS) examination, which indicated severe cognitive impairment. […]

• Actual harm, isolatedF692Oct 12, 2022

  Based on observations, interviews, policy review and record reviews, the facility failed to 1) address significant weight loss for 2 Residents (#17 and #82) out of a total sample of 36 residents. Findings include: Review of the facility policy titled, Weight Assessment and Intervention, revised March 2022, indicated the following: *Residents are weighed upon admission and at intervals established by the interdisciplinary team such as weekly for four weeks, then monthly unless otherwise indicated or as ordered. *A weight change of 5 lbs (pounds) or more in a patient weighing more than 100 lbs or of 2 lbs in a patient weighing less than 100 lbs since the last weight assessment will be retaken for validation. If the weight is verified, nursing will notify the Dietitian. […]

• Actual harm, isolatedF697Oct 12, 2022

  Based on observation, interview, and record review the facility failed to address pain after 1 Resident (#38) verbally expressed pain in the right leg, out of a total sample of 36 residents. Findings include: Review of the facility policy titled Pain Assessment and Management, dated 5/19/20, indicated the following: - Pain management is a multidisciplinary care process that includes the following: - Assessing the potential for pain - Recognizing the presence of pain - Identifying the characteristics of pain - Addressing the underlying causes of pain - Developing and implementing approaches for pain management - Identifying and using specific strategies for different levels and sources of pain - Monitoring the effectiveness of interventions and modifying approaches as necessary Cognitive,… […]

• No harm, potential for more than minimal, patternF550Dec 18, 2025

  Based on observation, record review and interview, the facility failed to maintain a dignified existence for four Residents (#4, #20, #116 and #6) out of a total sample of 25 residents. Specifically,For Residents #4 and #20 the facility failed to maintain a dignified experience during meals by leaving the tray in front of the Resident for an extended period of time before providing assistance and standing over the Resident while assisting with the meal.For Resident #116 the facility failed to ensure that the Resident's chest was not visible from the hallway.For Resident #6 the facility failed to ensure that the Resident's privacy was maintained when their brief was visible from the hallway.Findings include:Review of facility policy titled Dignity, dated as revised February 2021, indicated… […]

• No harm, potential for more than minimal, patternF695Dec 18, 2025

  Based on observation, interviews, and record review, the facility failed to ensure that respiratory care and services, consistent with professional standards of practice, were provided for three Residents (#88, #68 and #14) out of sample of 25 residents. Specifically,For Resident #88 the facility failed to properly label and store respiratory supplies and failed to administered oxygen as per the physician's orders.For Resident #68 and Resident #14 the facility failed to properly label and store respiratory supplies.Findings include:Review of facility policy titled Oxygen Administration, dated as revised October 2010, indicated the following: -Verify that there is a physician's order for this procedure. Review the physician's orders for facility protocol for oxygen administration. 1. […]