Briarfield Place

Based on record review and interview, the facility failed to inform residents of the risks, benefits, and alternative treatment options prior to initiating new psychotropic medications. This affected one resident (#7) out of five reviewed for unnecessary medications. The facility census was 47. Findings include:Review of the medical record for Resident #7 revealed an admission date of 05/25/25 with diagnoses including cerebral infarction, depression, and anxiety. Review of the care plan dated 06/09/25 revealed Resident #7 used psychoactive medications. Interventions included provide medications as ordered by the physician, monitor mental status, monitor mood and behavior changes, observe resident's interactions with others, and pharmacy to review medication regimen per facility policy. Review of the Nurse Practitioner (NP) progress note dated 06/13/25 revealed Resident #7 had poor oral intake at meals with minimal improvement after diet texture upgrade. New orders were added for Remeron/Mirtazapine (an antidepressant) 7.5 milligrams (mg) once daily at bedtime for seven days and then…

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, record review, interview and review of facility policy, the facility failed to ensure food was served in a sanitary manner. This had the potential to affect all 52 residents in the facility, as the facility identified all 52 residents received meals from the kitchen. The facility census was 52. Findings include: 1. Observation of the kitchen on 04/30/24 from 11:12 A.M. to 11:26 A.M. revealed Food Service Director (FSD) #406 had a noticeable growth of facial hair and wasn't wearing a beard guard in the kitchen as he ran the bowl and lid to the commercial blender and a spatula through the dish machine. Interview on 04/30/24 at 11:26 A.M. with FSD #406 confirmed he wasn't wearing a beard guard and had never worn a beard guard in the kitchen. Interview on 04/30/24 at 11:26 A.M. with Dietitian #331 stated staff with beards in the kitchen should be wearing beard guards and confirmed FSD #406 had not been wearing a beard guard and should have been. Review of the facility's undated policy Proper…

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, medical record review, staff interview and policy review the facility failed to ensure peripherally inserted central catheters (PICC) were flushed appropriately and as ordered by the physician. This affected one (Resident #113) of five residents reviewed for medications. The facility identified three residents (102, 103 and 113) with current PICC line or intravenous (IV) lines for medication administration. The facility census was 52. Findings include: Observation on 04/30/24 at 12:05 P.M. revealed Licensed Practical Nurse (LPN) #372 administering ceftriaxone (antibiotic) 2000 milligram (mg) through a PICC line for Resident #113. LPN #372 had the medication solution, two 10 milliliter (ml) syringes of 0.9% normal saline (NS) and one 5 ml syringe of heparin (blood thinner) 100 units (u) per ml. LPN prepared the PICC line tubing by cleaning the caps with alcohol and then flushed with 10 ml of NS, then flushed with 3 ml of the heparin and then another flush with 10 ml of NS. At this time LPN #372 connected the ceftriaxone to the PICC line and began the medication…

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, resident interview, medical record review, review of manufacturer's instructions and staff interview the facility failed to ensure respiratory equipment including continuous positive airway pressure (CPAP) equipment were properly cleaned per manufacturer's instructions. This affected one resident (Resident #9) of three residents reviewed for respiratory equipment use. The facility census was 52. Findings include: Observation of Resident #9 on 04/29/24 at 2:05 P.M. revealed a CPAP machine on the bedside stand. Interview with Resident #9 on 04/29/24 at 2:05 P.M. revealed staff do not clean her CPAP mask, tubing or machine on a routine basis. Review of Resident #9's medical record revealed an admission date of 06/09/22 with diagnoses including obstructive sleep apnea, congestive heart failure and chronic obstructive pulmonary disease. Further review of the medical record revealed on 12/29/23 the resident was ordered the use of a CPAP machine. No evidence of any cleaning of the machine, tubing or mask was found within the medical record. Review of the care plan for…

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 review of the facility policy the facility failed to ensure all food was labeled, dated, and discarded properly. The facility identified all residents received food from the kitchen, which had the potential to affect all 49 residents. Findings include: During the initial kitchen tour conducted on 06/20/23 between 8:22 A.M. and 8:35 A.M. the following was observed and verified with Food Service Director (FSD) #612. Observation of the walk-in freezer revealed: • One gallon storage bag of chicken breasts was not dated. • One gallon storage of sliced unknown meat, according to the FSD #612, was not labeled or dated. • One opened and resealed half full bag of tator tots was not dated when opened. • One gallon storage bag of breaded chicken thighs was not dated. Observation of the walk-in cooler revealed: • One opened and resealed half full bag of shredded mozzarella cheese was not dated when opened. • One opened and resealed bag of cheddar cheese chunks was not dated when opened. • One opened and resealed bag of four croissants was not dated…

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 review of Baseline Care Plan facility policy revealed the facility did not ensure baseline care plans were implemented and/ or that the resident and/ or resident representative received a copy of the baseline care plan within 48 hours of admission that included goals, objectives, and interventions of the residents' current needs. This affected four residents (#56, #161, #165, and #170) out of 26 residents reviewed for care plans. The facility census was 49. 1. Review of medical record for Resident #165 revealed an admission date of [DATE] and she was discharged on [DATE]. Her diagnoses included moderate protein-calorie malnutrition, abnormal involuntary movements, restlessness, agitation, and difficulty walking. No baseline care plan was noted in her medical record that included goals, objectives, and interventions of her current needs. Review of Fall Risk Assessment dated [DATE] and completed by Registered Nurse (RN) #639 revealed Resident #165 was at moderate…

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 medical record review, interview, and facility policy review the facility failed to ensure a resident's wish regarding end-of-life measures was clearly identified in the medical record. This affected one (Resident #39) of 24 residents screened for Advanced Directives. Findings include: Review of Resident #39's medical record revealed diagnoses including fracture of the left pubis, chronic obstructive pulmonary disease, Parkinson's disease, generalized anxiety disorder, psychosis, chronic ischemic heart disease, severe protein-calorie malnutrition, dementia, adult failure to thrive and cerebrovascular disease. Review of a DNR (Do Not Resuscitate) form dated 10/25/22 revealed a Do Not Resuscitate Comfort Care (DNRCC) order. Review of physician orders revealed an order dated 11/15/22 for a Do Not Resuscitate Comfort Care Arrest (DNRCC-A). Information along the top of the record located near the allergy list and the care plan (initiated 11/29/22) also indicated a DNRCC-A status. On 06/21/23 at 11:59 A.M., the Director of Nursing (DON) stated there was a separate book with code…

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 medical record review, interview, and facility policy review the facility failed to revise care plans for two residents (#15 and #16) of 27 residents whose care plans were reviewed. The facility census was 49. Findings include: 1. Review of Resident #15's medical record revealed diagnoses including major depressive disorder and generalized anxiety disorder. A care plan initiated 07/08/22 indicated Resident #15 used psychoactive medication and had a history of anxiety, depression, and PTSD (Post Traumatic Stress Disorder). Interventions included monitoring mood and behavior changes, providing medication as ordered, and monitoring mental status. A psychiatrist note dated 03/01/22 indicated Resident #15 had a lot of anxiety and worry. Staff reported increased depression/anxiety especially once the Russian/Ukraine conflicts started. The note indicated Resident #15 had some PTSD issues. Medication changes were made, including discontinuation of trazodone (antidepressant), starting Cymbalta (antidepressant)…

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 interview, record review, and review of weight policy revealed the facility did not ensure weights were obtained as ordered by the physician and/ or per facility policy. This affected two residents (#161 and #164) out of four residents reviewed for nutrition. The facility census was 49. Findings include: 1. Review of the medical record for Resident #161 revealed an admission date of 06/13/23 with diagnoses including hypertension, retention of urine, and chronic ischemic heart disease. Review of the June 2023 Medication Administration Record (MAR) and June 2023 Treatment Administration Record (TAR) revealed no weights were documented. Review of the BCP (Baseline Care Plan)/Admit/ Readmit Screener dated 06/13/23 revealed per the assessment Resident #161 was on a regular diet with thin liquids. There was nothing else added including he was on daily weights as ordered per the physician as an intervention. Review of the Weight Summary for Resident #161 dated from 06/13/23 to 06/20/23 revealed Resident #161…

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 interview, observation, record review, and facility policy review the facility did not ensure Resident #167 had an order for oxygen and had appropriate signage indicating oxygen was in use on her door. This affected one resident (#167) out of two residents reviewed for respiratory therapy. This had the potential to affect eight residents (#13, #15, #21, #164, #167, #171, #173, and #258) receiving oxygen. Findings include: Review of the medical record for Resident #167 revealed an admission date of 06/01/23 with diagnoses including acute cystitis with hematuria, plural effusion, hypertension, and chronic ischemic heart disease. Review of the Physician Orders for June 2023 revealed Resident #167 had no current oxygen order as well as no previous oxygen orders in her medical record from 06/01/23 to 06/20/23. Review of the comprehensive care plan dated 06/01/23 revealed Resident #167 did not have a care plan regarding her respiratory issues and need for oxygen. Review of the Oxygen Saturation Summary dated from 06/02/23 to 06/20/23 revealed there was at least one entry per day…

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.