Briar Hill Health Campus

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure resident assessments were completed timely. This affected one (#41) of two residents review for discharged resident assessments. The census was 43. Findings include: Review of the closed medical record review revealed Resident #41 was admitted on [DATE] and discharged home on [DATE]. Diagnoses included fracture of unspecified part of neck of left femur, hypertensive chronic kidney disease, chronic kidney disease stage 4, essential (primary) hypertension, non-Hodgkin lymphoma, and unspecified osteoarthritis. Review of the Minimum Data Set (MDS) assessment, dated 01/09/24, revealed the resident had an admission assessment completed. No further MDS assessments were entered. Interview on 06/18/24 at 4:37 P.M., with Licensed Practical Nurse (LPN) #559 and Corporate Registered Nurse (RN) #591 verified Resident #41 did not have a discharge MDS assessment completed.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review and staff interview, the facility failed to ensure an accurate resident assessment was completed for an anticoagulant medication. This affected one (#21) of thirteen residents reviewed for accurate resident assessments. The facility census was 43. Findings include: Review of the medical record revealed Resident #21 was admitted on [DATE]. Diagnoses included atherosclerotic heart disease of native coronary artery without angina pectoris, unspecified dementia, type two diabetes mellitus without complications, major depressive disorder, anxiety disorder, and essential hypertension. Review of the Minimum Data Set (MDS) assessment, dated 05/06/24, revealed the resident was rarely understood. According to the MDS assessment one of the high-risk medications the resident was taking included anticoagulant medications. Review of physician orders dated April and May 2024 (including discontinued orders) and current orders for June 2024, revealed no anticoagulant medications had been…

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 a facility policy, the facility failed to properly store foods and maintain the kitchen in a sanitary manner. This affected all 49 residents in the facility who the facility identified as receiving food from the kitchen. Findings include: Observation of the facility kitchen on 12/19/21 at 9:45 A.M. revealed pre-sliced deli meats stored in a plastic bin on the bottom shelf of the walk in refrigerator. Inside the plastic bin revealed opened bags of bologna, corned beef, pepperoni, ham, and turkey which were placed inside plastic zip sealed bags inside the plastic bin. The bag of ham had a slimy liquid covering the bag. Further inspection revealed a slimy liquid covered all the bags of meat inside the plastic bin and a bag of sliced bologna was noted to not be fully sealed and leaking the slimy liquid. Observation of a food label sticker placed on the bag of bologna revealed a used by date of 11/28/21. A second bag of bologna inside the plastic bin had a food label sticker with a used by date of 12/13/21. Interview on 12/19/21 at…

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 and resident interview, and review of facility policies, the facility failed to assess a resident to determine their appropriateness for self-administering medications. This affected one (#42) of five residents reviewed for unnecessary medications. The facility identified no current residents assessed as able to self-administer their medications. The census was 49. Findings include: Review of Resident #42's medical record revealed an admission date of 01/05/21. Diagnoses included unspecified dementia with behavioral disturbances, dry eye syndrome of the unspecified lacrimal gland, spinal stenosis, major depression, acute kidney failure, paranoid personality disorder, and delusional disorders. Review of the most recently completed Minimum Data Set (MDS) assessment, dated 12/02/21, revealed Resident #42 had intact cognition. Review of Resident #42's comprehensive care plan, last reviewed on 10/18/21, revealed no care plan for Resident #42 to self-administer medications. Review of a physician order dated 12/03/21 revealed Resident #42…

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 resident interview, observation, staff interview, and review of facility policy, the facility failed to maintain a clean and sanitary environment. This affected two (#32 and #44) of 24 residents reviewed for environment. The facility census was 49. Findings include: Review of the medical record for Resident #32 revealed ad admission date of 11/03/21. Diagnoses included COVID-19, cerebral infarction (stroke), type II diabetes, chronic obstructive pulmonary disease (COPD), and major depressive disorder. Additional review of the quarterly Minimum Data Set (MDS) assessment, dated 11/26/21, revealed Resident #32 was cognitively intact, required supervision with toilet use, and was always continent of bowel and bladder. Review of the medical record for Resident #44 revealed an admission date of 09/12/21. Diagnoses included wedge compression fracture of the second and fourth lumbar vertebra, heart disease, end stage renal disease, type II diabetes, difficulty walking, lack of coordination, and muscle weakness. Additional review of the quarterly MDS assessment, dated 11/27/21,…

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, medical record review, and staff interview, the facility failed to monitor for edema and ensure non-pharmaceutical interventions were implemented to minimize the occurrence of lower extremity edema for one (#36) of 24 residents reviewed for timely care and treatment. The facility census was 49. Findings include: Review of the medical record for Resident #36 revealed an admission to the facility on [DATE]. Diagnoses included Alzheimer's disease, dementia, type 2 diabetes mellitus, liver disease, anemia, hyperlipidemia, benign prostatic hyperplasia, COVID-19, peripheral vascular disease, hypertension, depression, and history of acute kidney failure. Review of the most current Minimum Data Set (MDS) assessment, dated 11/25/21, identified the resident with moderately impaired cognition, requires staff supervision for the completion of activities of daily living, utilizes a wheel chair for mobility, frequently incontinent of bladder, continent of bowel, and receives a diuretic medication daily.…

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, medical record review, resident interview, and staff interview, the facility failed to follow up with a physician for treatment of fungal infection on the toe nails for one (#24) of 24 residents reviewed for comprehensive foot care. The facility census was 49. Findings include: Review of the record for Resident #24 revealed an admission to the facility on [DATE]. Diagnoses included metabolic encephalopathy, urinary tract infection, acute kidney failure, dysphasia, atrial fibrillation, chronic kidney disease, major depression, dementia, cerebral vascular disease, and hypertension. Review of the Minimum Data Set (MDS) assessment, dated 11/15/21, Resident #24 was alert, able to make needs known, dependent on staff for the completion of activities of daily living, and at risk for skin breakdown with no concerns listed. Review of a physician clinical note dated 12/01/21 documented Resident #24 with multiple toenails with fungal infection. The clinical note lacked documentation implementing a…

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, observation, staff interview, and review of Safety Data Sheet, the facility failed to ensure hazardous chemicals on the 100-Hall of the facility were secured. This had the potential to affect one resident (#251) residing on the 100-Hall, and identified by the facility as being cognitively impaired and independently mobile. The facility census was 49. Findings include: Review of the medical record revealed Resident #251 was admitted on [DATE]. Diagnoses included COVID-19, altered mental status, dementia with behavioral disturbance, and schizoaffective disorder. Review of the admission Minimum Data Set (MDS) assessment, dated 12/13/21, revealed Resident #251 was severely cognitively impaired. Observation on 12/19/21 at 10:11 A.M. of the soiled linen room located next to the shower room on the 100-Hall revealed the door was not locked. Inside the soiled linen room was a cabinet hanging on the wall. A sign posted on the cabinet stated not to leave the key in the lock. Further…

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, resident interview, staff interview, and family interview, the facility failed to preserve the dignity of one resident by having her use a bedside commode instead of providing her assistance to use the toilet in the bathroom which would provide privacy. This affected one (Resident #7) of one resident reviewed for resident rights. The census was 45. Findings include: Review of the medical record revealed Resident #7 was admitted on [DATE]. Diagnoses included dementia with behavioral disturbances, unspecified lack of coordination, mono-arthritis, left knee, pain in right wrist, muscle weakness and difficulty in walking. Review of the plan of care for Resident #7 revealed the resident was at risk for falling related to a history of falls and decline in her Activity of Daily Living (ADL)'s. Her goal was to remain free from falls with major injury. Her interventions included the resident required two staff assistance with transfers and to encourage the commode during bedtime 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on medical record review, observation, resident interview, and staff interview, the facility failed to provide a resident with a special shoe accommodation. This affected one Resident (#37) of three residents reviewed for accommodations. The facility census was 45. Findings include: Review of Resident #37's medical record revealed an admission date of 05/14/15. Diagnoses included atherosclerotic heart disease, rheumatoid arthritis, hypertension, wedge compression fracture of the first lumbar vertebra, osteoarthritis, muscle weakness, difficulty walking, history of falling, anxiety disorder, and diabetes mellitus. Review of the physician orders revealed an order dated 12/11/18 for Resident #37 to be fitted for diabetic shoes. Review of the progress notes dated 12/12/18 at 11:18 A.M., revealed notification had been made to a shoe company initiating the process of retrieving diabetic specialty shoes for Resident #37. Review of Resident #37's quarterly Minimum Data Set (MDS) assessment dated [DATE] revealed…

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.