Briar Hill Rest Home

Based on observation, facility policy review, and interviews, the facility failed to ensure residents were provided with reasonable accommodations to maintain a safe and functional environment by failing to keep call lights within physical reach for seven (7) of ten (10) sampled residents. Residents #4, #5, #6, #7, #8, #9, and #10.Findings Included:Record review of the facility policy Call Light Policy, revised January 12, 2015, revealed, .1. All facility personnel must be aware of call lights at all times.11. Be sure all call lights are placed conveniently for the resident.On 5/28/26 at 4:01 PM, observation revealed Resident #7 and Resident #10 did not have their call lights within their reach.On 5/28/26 at 4:05 PM, observation and interviews revealed that Resident #5 and Resident #8's call lights were out of reach and stuck (could not be pulled out easily) under Resident #5's bed. Observation revealed that Resident #5 had to get off her bed and it took Licensed Practical Nurse (LPN) #1 two minutes and moved the bed several times for LPN #1 to retrieve the call lights from under…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, and facility policy review, the facility failed to provide a safe, functional, and sanitary environment for residents as evidenced by failing to maintain sharps containers in a safe manner for two (2) of four (4) observed sharps containers.Findings Included:Record review of the facility policy Sharps Container Policy, undated, revealed The facility will utilize sharp container as follows: For disposal of all sharp items, (not all inclusive) .Lancets.Sealed with tape and dated when disposed of. The facility policy did not address when or how often the sharps containers should be emptied. On 5/28/26 at 3:40 PM, during an observation and interview the Director of Nursing (DON) revealed the sharps container in the shower room on the locked dementia unit was full to the point of being unable to be opened and there were three uncapped used aqua-blue disposable razors on the top of the container. The DON confirmed that the sharps container should have been properly disposed of and replaced with a new one and that the razors on top of the container could…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review the facility failed to provide information for pertinent state agencies and advocacy groups, specifically the ombudsman for two (2) of three (3) days of survey. Findings include: Record review of facility grievance policy Resident and Family Grievances reviewed 2/24/19 revealed, .Information on how to file a grievance or complaint will be available to the resident. Information may include but is not limited to. 7.a. The contact information of the grievance official with whom a grievance can be filed, including his or her name. business address (mailing and email) and business phone number. b. The contact information of independent entities with whom grievances may be filed, that is, the pertinent State Survey Agency and Local Long-Term Care Ombudsman program or protection and advocacy system. c. The time frame that a resident may reasonably expect completion of the review of the grievance and a written decision regarding his or her…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, and facility policy review the facility failed to ensure that services were provided in accordance with professional standards of practice and within staff scope of practice for one (1) of four (4) residents reviewed for enteral nutrition services. (Resident #6) Findings Include:Record review of the facility policy Tube Feeding undated revealed, .Responsibility: All licensed Nursing personnel monitored by the Charge Nurse .On 1/21/26 at 2:30 PM, an observation of Certified Nursing Assistant #2 (CNA) doing incontinent check on Resident #6 revealed she placed feeding pump on hold prior to checking the resident. CNA #2 left the room to obtain supplies for incontinent care.On 1/21/26 at 2:35 PM, during an interview with CNA #2 revealed they let us place the pump on hold when do incontinent check on resident before we let the bed down flat. She stated when they finished, they were told to turn the pump back on. She stated she watched the nurses operate pump and know…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review and facility policy review, the facility failed to ensure a resident received necessary grooming assistance in accordance with her preferences for one (1) of (15) residents reviewed for Activities of Daily Living (ADLs). Resident #41Findings include:A review of the facility policy, Resident Rights, undated, revealed .5. Respect and dignity. The resident has the right to be treated with respect and dignity During an interview with Resident #41 on 1/20/26 at 11:20 AM, she stated that the staff do not shave under her arms. She reported that when she lived at home, she shaved under her arms every day or as often as needed. She added that if staff shaved under her arms at least once a week, she would be satisfied.During an observation on 1/20/26 at 11:21 AM, revealed Resident #41's underarm hair to be thick and approximately two and one-half (2.5) inches long.During an interview with Certified Nursing Assistant (CNA) #1 at 10:20 AM on 1/21/26, the CNA stated that shaving under the arms is part of the ADLs for residents. She explained that it…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, and facility policy review, the facility failed to store food and maintain sanitary practices in accordance with professional standards for food safety related to unlabeled foods, foods without identified dates, exposed foods, and overly ripe produce for one (1) of two (2) kitchen observations. Findings Include: A review of the facility's policy, Storage of Refrigerated Food, revised 10/17, revealed, The facility ensures the quality and safety and sanitation of refrigerated foods through accepted storage practices. Procedure .4. No food is left uncovered. 5. All opened foods are labeled with common name of food, date stored, and use-by date . On 08/13/24 at 9:19 AM, during an observation of the kitchen and interview with the Certified Dietary Manager (CDM), Refrigerator #1 had nine (9) overly ripe tomatoes containing white biological growth on each tomato. There was (1) unopened bag of salad mix with a facility received sticker of 8/7/24, with no manufacturer's date, and a brown…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews, record review, and facility policy review, the facility failed to ensure a resident was free from exploitation for one (1) of 16 sampled residents. Resident #12. Findings Include: A review of the facility's policy, Resident Rights, dated 2018, revealed: 1. Resident Rights. The resident has the right to a dignified existence, self-determination .5. Respect and Dignity. The resident has a right to be treated with respect and dignity . A review of the facility's policy, Abuse, Neglect and Exploitation, reviewed/revised 5/25/24, revealed: Policy: It is the policy of this facility to provide protection for the health, welfare and rights of each resident by developing and implementing written policies and procedures that prohibit and prevent abuse, neglect, exploitation and misappropriation of resident property . Definitions: Exploitation means taking advantage of a resident for personal gain .Mistreatment means inappropriate treatment or exploitation of a resident . IV.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews, record reviews, and facility policy reviews, the facility failed to implement/follow the care plan for three (3) of sixteen (16) sampled residents. Resident #12, Resident #13, Resident #48 Findings Include: A review of the facility policy titled Care Plans, updated 2/3/23 revealed, Policy: Each resident will have a person-centered plan of care to identify problems, needs and strengths that will identify how the interdisciplinary team will provide care .Resident Care Summary-part of the Comprehensive Care Plan is used as the tool to make staff aware of the resident's daily care needs . Resident #12 A record review of the ADL (Activities of Daily Living) comprehensive Care Plan dated 1/29/24, revealed an intervention related to transfers as Transfers: Extensive Two Person Assist At 1:05 PM on August 13, 2024, as Certified Nursing Assistant (CNA) #2 recapped what she saw in the social media video, she specifically pointed out that she saw CNA #1 grab the resident under the arm and move her to the geriatric chair without assistance. She stated the transfer was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and policy review the facility failed to ensure a two-person transfer, as evidenced by video evidence of a Certified Nursing Assistant (CNA) transferring a resident from the bed to the geriatric chair by herself. The resident required a 2-person transfer. This was for one (1) of 16 sampled residents. Resident # 12. Findings Include: A review of the facility policy titled Modified Lifting Policy, no date, reveals, .Facility will provide a safe work environment for patient care areas by providing and requiring the use of safety materials, equipment and training designed to prevent personnel and patient injury .It is crucial that health care professionals practice safe lifting, transporting . At 1:05 PM on 8/13/24, as Certified Nursing Aide (CNA) #2 recapped what she saw in the social media video, she specifically pointed out that she saw CNA #1 put the geriatric chair in front of the resident's bed. She remembers seeing CNA #1 grab the resident under the arms and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, staff interview, and facility policy review, the facility failed to post the direct care daily staffing numbers in a location accessible to residents and visitors for two (2) of three (3) days of survey. Findings Include: Review of the facility ' s policy, Nurse Staffing Posting Information, revised 2/3/2023, revealed, .It is the policy of this facility to make staffing information readily available in a readable format to residents and visitors at any given time. Policy Explanation and Compliance Guidelines: 1. The nurse staffing information will be posted on a daily basis .2. The facility will post the nursing staffing data at the beginning of each shift . On 8/13/24 at 9:30 AM, there were no direct care daily staffing numbers posted in the facility. On 8/14/24 at 8:30 AM, there were no direct care daily staffing numbers posted in the facility. On 8/15/24 at 10:15 AM, in an interview with the Director of Nursing, she stated she was aware the nursing staffing had to posted in a prominent place that was readily accessible to residents and visitors at the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, record review, and facility policy review, the facility failed to ensure their medication error rate was less than five percent as evidenced by three (3) errors were observed out of twenty-six (26) medication administration opportunities. This affected two (2) of seven (7) residents observed during medication pass, resulting in a medication error rate of 11.54%. (Residents #48 and #13) Findings include: A review of the facility's policy titled, Medication Administration General Guidelines, (undated) revealed, Medications are to be administered as prescribed in accordance with good nursing principles and practices .Procedure .2. Medications are to be administered in accordance with the written orders of attending physicians, taking into consideration manufacturer's specifications, and professional standards of practice . A review of the facility's policy titled, Ordering and Receiving Medications from Pharmacy, (undated) revealed, Medications are ordered and received from the pharmacy in a timely manner .Procedure . 2. A. Re-order medication in…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record review, and facility policy review, the facility failed to serve therapeutic portion sizes of foods as planned per the facility's menu for one (1) of seven (7) food items requiring specific portions on the lunch meal tray line. Resident #40 Findings Include: A review of the facility's policy, Tray Assembly, revised 6/17, revealed, .Prepared foods are portioned and assembled for individual meals in the food and nutrition services department. Procedure .6. Menu items and equipment are positioned in reach of the food service employees. These items include .c. Serving utensils as specified on the menu and equipment needed for correct portions .10. Portions are .weighed on portion scales . A record review of the facility's Menu Guide Report for Spring/Summer 2024 revealed the following portion sizes to be served at lunch: 3 ounces of country meatloaf, 1/3 cup of mashed potatoes,1-ounce brown gravy, 1/3 cup of buttered green peas, one (1) fresh baked roll, one (1) piece of confetti cake with icing, and one (1) cup of iced tea. On 08/13/24 at 10:51…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interviews, record reviews, and facility policy review,the facility failed to provide incontinent care in a manner to prevent possible urinary tract infections for one (1) of five (5) observations of incontinent care. Resident #49. Findings include: Review of the facility's policy, Incontinent Care, undated, revealed, To provide routine, preventative skin, perineal care to residents after an incontinent episode .When washing perineal area, wash the perineal area from front to back. For the male resident retract the foreskin while using clean area of the washcloth or adult wipes for each stroke . During an observation of incontinent care on 1/17/23, at 11:33 AM, Certified Nurse Aide (CNA) #1 failed to use a clean area of the adult wipe while cleaning the penis of Resident #49. CNA #1 cleansed the resident's scrotum with an adult wipe by wiping several times with the same wipe, then used the same wipe and same area of the wipe to cleanse the head of Resident #49's penis. During an interview on 1/19/23, at 11:00 AM, CNA #1 confirmed while providing perineal care…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.