Millbrook Healthcare and Rehabilitation Center

In the surveyor’s words

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

• Immediate jeopardy, patternF880Nov 29, 2023

  Based on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases for five (LVN A, Medical Records Staff B, OTA C, OTA D, and OT E) out of ten staff reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure LVN A wore an N95, or equivalent, mask over her mouth and nose at all times when in quarantined rooms with residents positive for COVID-19, including while suctioning a COVID-19 positive resident, according to the facility's policy. 2. […]

• Immediate jeopardy, patternF580Feb 10, 2023

  Based on interview and record review, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's physical status and a need to alter treatment significantly for one (Resident #1) of 5 resident reviewed for changes in condition. The facility failed to notify the physician when the resident began having seizures and required hospitalization s on 12/03/22, 12/04/22 through 12/08/22, and 12/12/22 through 12/23/22 as evidence of the failure to monitor diagnostic lab work and to follow the pharmacy's recommendation to obtain orders for lab levels. This failure resulted in identification of Immediate Jeopardy (IJ) on 1/20/2023 at 4:40 p.m. The IJ was removed on 1/21/2023 at 3:50 P.M. […]

• Immediate jeopardy, patternF757Feb 10, 2023

  Based on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs and included adequate monitoring for high-risk medications for 1 (Resident #1) of 5 residents reviewed for antiseizure medications. The facility failed to Monitor Resident #1 antiseizure medications therapeutic blood levels. -Resident #1 was transferred to the hospital three different times in the month of December 2022 because the DON deemed the transfer to the emergency room was necessary due to unstable symptoms of altered mental status. The facility failed to follow up on the pharmacist consult recommended antiseizure medication interaction to ensure therapeutic medication labs were ordered and uploaded to Resident #1's medical record. […]

• Actual harm, isolatedF689May 12, 2022

  Based on interviews, observations, and record review, the facility failed to ensure a resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of six residents reviewed for safety, accident/hazards and supervision, in that: On 04/15/2022 CNA A failed to use a two-person transfer, based on the resident's level of assistance, during a transfer from the resident's wheelchair to the shower chair. The Resident was later diagnosed with a [CONDITION(S)]. sustaining an injury of an unknown origin. […]

• No harm, potential for more than minimal, widespreadF812Sep 1, 2021

  Based on observation, interview, and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure unpasteurized or raw eggs were stored appropriately to prevent foodborne illness. 2. The facility failed to ensure dry foods and goods are stored in a manner that maintains the integrity of the packaging until they are ready to use. 3.The facility failed to ensure the proper labeling and dating of all foods stored in the refrigerator or freezer. 4. The facility failed to ensure the dry good area was free of bugs and insects. […]