Mill Brook Rehabilitation and Healthcare Center

In the surveyor’s words

From the most serious findings on record at Mill Brook Rehabilitation and Healthcare Center, in the surveyor’s own words.

• Actual harm, isolatedF580Mar 2, 2023

  Based on observations, interview, and record review, the facility failed to ensure a physician was notified of changes for one Resident (#45) in order to alter the treatment, in a total sample of 21 residents. Specifically, the facility failed to notify the physician of a recommendation to change the treatment for a wound on the right great toe. Findings include: Resident #45 was admitted to the facility in November 2017 with diagnoses including type 2 diabetes mellitus. Review of the medical record indicated a diabetic ulcer to the right great toe was identified in February 2023. […]

• Actual harm, isolatedF686Mar 2, 2023

  NOT CORRECTED Based on observations, interviews, and record review, the facility failed to ensure one Resident (#91), out of a total sample of 17 residents, received care and treatment to prevent and to promote healing of a pressure injury. Specifically, the facility failed to implement treatments as ordered, notify the physician, and reassess worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to an unstageable pressure area to the Resident's coccyx. […]

• Actual harm, isolatedF686Mar 2, 2023

  NOT CORRECTED Based on observations, interviews, and record review, the facility failed to ensure one Resident (#91), out of a total sample of 17 residents, received care and treatment to prevent and to promote healing of a pressure injury. Specifically, the facility failed to implement treatments as ordered, notify the physician, and reassess worsening Moisture-Associated Skin Damage (MASD-inflammation and erosion of the skin caused by prolonged exposure to various sources of moisture, including urine or stool) resulting in a delay in treatment and deterioration of the wound to an unstageable pressure area to the Resident's coccyx. […]

• Actual harm, isolatedF689Mar 2, 2023

  Based on policy review, record review, and interviews, the facility failed to maintain an environment free of accident hazards for one Resident (#53), out of a sample of 21 residents. Specifically, the facility failed to ensure an adverse medication event, which necessitated the Resident to be emergently transferred to the hospital for evaluation and resulted in psychosocial distress to the Resident, was investigated and reported according to facility policy. Findings include: Review of the facility's policy titled Accidents and Incidents, last revised [DATE], included but was not limited to: -It is the policy of the facility to monitor and evaluate all occurrences of accidents or incidents or adverse events occurring on the facility's premises which is not consistent with the routine… […]

• Actual harm, isolatedF600Dec 20, 2022

  Based on records reviewed and interviews, for one of three sampled residents (Resident #1), who was cognitively intact, whose primary language was Portuguese, but was able to make his/her needs known to staff, the Facility failed to ensure he/she was free from verbal abuse by a staff member. On 12/11/22 at approximately 6:50 P.M., Certified Nurse Aide (CNA) #1 engaged in a verbally abusive altercation with Resident #1, that took place at the Nurse's Station and was witnessed by other staff members. CNA #1 told Resident #1 to shut up, that he/she was a drunk and that was why his/her spouse left him/her. Resident #1 became visibly upset, anxious, agitated, tried to get up from his/her wheelchair to confront CNA #1, and fell . […]