Briarwood Community Living Center

Based on policy review, observation, and interview, the facility failed to ensure food was stored, handled, prepared, and served under sanitary conditions, when large quantities of gray dust were found on overhead pipes, chains supporting the vent hood, and air conditioner/return vents; when plastic containers holding dry food items had dried substances and loose particles on top of the lids; when stainless steel tables, metal storage racks, and the steam table, were found with a brown substance that has the appearance of rust on the legs; and when the steam table had a black substance build up at the base of the legs; when a running streak of dried brown substance was found on the outside of the vent hood; when a discolored paper was found stuck underneath the rim of the vent hood; when white flakey and dark brown particles were found on the lower shelf of the milk cooler; and when a large round brown dried stain was found on the shelf paper in the cabinet where the plastic drinking glasses were stored. The facility had a census of 33 with 33 of those residents receiving a tray…

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 facility policy review, facility investigation review, medical record review, and interview, the facility failed to report a staff to resident allegation of verbal abuse for 2 of 2 (Resident #1 and #13) resident abuse allegations reviewed within the required timeframe. The findings included: 1. Review of the facility policy titled, Investigating Grievances and Concerns, dated 11/23/2016, revealed, .All reports of abuse, neglect, mistreatment, or misappropriation of property must be reported to the administrator within twenty-four (24) hours of their occurrence . 2. Review of the Facility Reported Investigation dated 1/2/2025, revealed an allegation of verbal abuse when Licensed Practical Nurse (LPN) F allegedly yelled at Resident #1 and #13. The alleged incident occurred on 12/28/2024. A call to the Director of Nursing (DON) was made by Registered Nurse (RN) G on 12/31/2024. The DON returned the call on 1/2/2025. The Administrator was notified, and the report was filed with the State agency on 1/2/2025,…

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 policy review, observation, and interview, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections for 5 of 12 (Residents #14, #17, #22, #28, and #29) residents when 3 (Housekeeper B, Certified Nursing Assistant (CNA) E, and Licensed Practical Nurse (LPN) A) staff members failed to change mop water and mop head after cleaning an isolation room and failed to clean resident reusable equipment before use. The findings included: 1. Review of the facility policy titled, Cleaning and Disinfection of Resident-Care Items and Equipment revised September 2022, revealed, .Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC recommendations for disinfection and the OSHA Bloodborne Pathogens Standard .Reusable items are cleaned and disinfected or sterilized between residents .Reusable resident care equipment is decontaminated and/or…

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 and interview, the facility failed to ensure a safe, sanitary, and comfortable environment for 2 of 5 (Resident #8, #12, #20, #24, #26, and #337) resident shared bathrooms observed. The findings include: 1. Review of the medical record revealed Resident #12 was admitted to the facility on [DATE], with diagnoses including Dementia, Chronic Obstructive Pulmonary Disease, Congestive Heart Failure, and Depression. Review of the quarterly Minimum Data Set (MDS) assessment dated [DATE], revealed a Brief Interview for Mental Status (BIMS) score of 5, indicating Resident #12 was severely cognitive impaired, and was dependent on staff for Activities of Daily Living skills (ADLs). 2. Review of the medical record revealed Resident #24 was admitted to the facility on [DATE], with diagnoses including Metabolic Encephalopathy, Anxiety, and Difficulty Walking. Review of the quarterly MDS assessment dated [DATE], revealed a BIMS score of 15, indicating Resident #24 was cognitively intact, and required staff…

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 policy review, observation, and interview, the facility failed to ensure food was stored, prepared, and served under sanitary conditions related to expired foods, unlabeled, undated, and uncovered food items, and carbon build-up on the eyes of the stove. The facility had a census of 40 with 38 of those residents receiving a tray from the kitchen. The findings include: 1. Review of the facility's policy titled, FOOD STORAGE, dated 8/29/2023, revealed .Food items should be stored, thawed, and prepared in accordance with good sanitary practice. Any expired or outdated food products should be discarded .All products should be inspected for safety and quality and be dated upon receipt, when open, and when prepared. Use by dates on all food stored in refrigerators and use dates .Leftovers should be dated .Remember to cover, label, and date .Frozen Meat/Poultry and Foods .Label and date all food items .Fresh vegetables .should be checked and sorted for ripeness .Most vegetables should be used within 3 to 5 days .Potentially hazardous foods including cut-leaf greens or tomatoes…

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 policy review, observation, and interview the facility failed to ensure practices to prevent the potential spread of infection were maintained when 3 of 3 nurses (Registered Nurse (RN A) (Licensed Practical Nurse (LPN B and LPN E) failed to clean a reusable eye medication bottle before she replaced the bottle into the medication cart, after taking the bottle in to a resident room, and when LPN B failed to ensure a reusable eye medication bottle was not cleaned, and when LPN E failed to ensure a FlexPen [a disposable, prefilled insulin pen that contains multiple doses of fast-acting insulin] was not disinfected before replacing in the medication cart. The findings include: 1. Review of the facility's policy titled, Cleaning and Disinfection of Resident- Care Items and Equipment, dated September 2022, revealed Resident-care equipment, including reusable items and durable medical equipment will be cleaned and disinfected according to current CDC [Centers for Disease Control and Prevention] recommendations…

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 the Resident Assessment Instrument Manual (RAI) User's Manual, medical record review, and interview the facility failed to accurately assess residents for smoking, medication review, and falls for 4 of 12 (Resident #28, #31, #34, and #38) sampled residents reviewed for accuracy of assessments. The findings include: 1. Review of the Resident Assessment Instrument (RAI) User's Manual dated October 2023, revealed .The RAI helps nursing home staff look at resident's holistically-as individuals for whom quality of life and quality of care are mutually significant and necessary . 2. Review of medical record review revealed Resident #28 was admitted on [DATE], with diagnoses including Cerebral Infarction, Hemiplegia, Aphasia, Nicotine Dependence, and Psychosis. Review of the Care Plan dated 7/1/2024 revealed, .I am a smoker . Review of the Smoking and Tobacco Evaluation, dated 11/19/2021 revealed Resident #28 does smoke. Facility is unable to provide an additional Smoking and Tobacco Evaluation, assessment…

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 policy review, medical record review, and interview, the facility failed to follow Physician's Orders related to antipsychotic medications for 1 of 5 (Resident #30) sampled residents reviewed for unnecessary medications. The findings include: 1. Review of the facility's policy titled, Physician's Orders dated 4/13/2021, revealed .Physician's orders are carried out unless the nurse or other licensed personnel believe the order to be inaccurate .Physician's orders are to be recorded in the medical record for each resident and are to be signed or initialed by the attending physician .Verbal or telephone orders are considered to be in writing when dictated by the physician or authorized health care professional and later signed .by said person . Review of the facility's policy titled, Antipsychotic Medication Use, dated 7/2022, revealed .Antipsychotic medications will be prescribed at the lowest possible dosage for the shortest period of time .All antipsychotic medications will be used within the clinically…

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 policy review, medical record review, and interview, the facility failed to have an order to monitor the dialysis shunt site every shift for 1 of 1 (Resident #29) sampled residents reviewed for dialysis. The findings include: 1. Review of the facility's policy titled End-Stage Renal Disease, Care of a Resident with dated 9/2010, revealed .Residents with end-stage renal disease (ESRD) will be cared for according to currently recognized standards of care .The general medical nurse should document in the resident's medical record every shift as follows .location of catheter .condition of dressing (interventions if needed) .If dialysis was done during shift .any part of report from dialysis nurse post-dialysis being given .Observations post-dialysis . 2. Medical record review revealed Resident #29 was admitted on [DATE], with diagnoses including End Stage Renal Disease, Heart Failure, and Diabetes. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed Resident #29's Brief Interview 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to ensure all residents were free of misappropriation of resident money for 2 of 2 (Resident #1 and #2) sampled residents reviewed for misappropriation. The findings include: 1. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 10/2022 revealed .All reports of resident abuse .misappropriation of resident property are reported to local, state and federal agencies .thoroughly investigated . documented and reported .if .misappropriation of resident property is suspected .suspicion must be reported immediately to the administrator .to the following agencies .state .agency responsible for surveying .ombudsman .resident's representative . Review of . Resident Rights, dated Nov. 28, 2016, revealed .facility shall exercise reasonable care for the protection of the resident's property from loss or theft . 2. Review of the medical record revealed, Resident #1 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 policy review, medical record review, and interviews, the facility failed to identify and report an alleged violation of misappropriation regarding residents' property to the administrator of the facility, the State survey agency, local law enforcement, and the Long-Term Care Ombudsman for 2 of 4 sampled residents (Resident #1 and # 2) reviewed for misappropriation. The Findings Include: 1. Review of the facility's policy titled, Abuse, Neglect, Exploitation or Misappropriation - Reporting and Investigating, dated 10/2022, revealed .All reports of resident abuse .misappropriation of resident property is to be reported to local, state, and federal agencies .thoroughly investigated by facility management. Findings of all investigations are documented and reported .if .misappropriation of resident property .is suspected .must be reported immediately to administrator and to other officials according to state law .The administrator .immediately reports his or her suspicion to the state agency .local…

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 policy review, facility investigation review, medical record review, and interview, the facility failed to thoroughly investigate allegations of resident misappropriation for 2 of 2 (Residents #1 and #2) residents reviewed for allegations of a misappropriation. The findings included: 1. Review of the facility's policy titled Abuse, Neglect, Exploitation or Misappropriation -Reporting and Investigating dated 10/2022 revealed .All reports of resident abuse .misappropriation of resident property are reported to local, state, and federal agencies (as required by current regulations) and thoroughly investigated by facility management. Findings of all investigations are documented and reported .Investigating Allegations .All allegations are thoroughly investigated. The administrator initiates the investigation .The individual conducting the investigation as a minimum: reviews the documentation and evidence, reviews the resident's medical record to determine the resident's physical and cognitive status 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on policy review, medical record review, and interview, the facility failed to maintain accurate medical records related to bed bath and/or shower documentation on 3 of 3 sampled residents (Resident #4, #25 and #30) The findings include: 1. Review of the policy titled, ADL (Activities of Daily Living) MONITORING POLICY dated 4/29/2029, revealed .Purpose .To decrease chances of inaccurate ADL Coding on a daily basis .CNA's (Certified Nurse ' s Aide) will have charge nurse .verify ADL .sheets are filled out prior to end of shift .check for accuracy . Review of the policy titled, Charting and Documentation Guidelines dated 3/22/2021, revealed all questions or fields on documentation fields/forms .should be completed. If a question or field is not applicable [N/A], N/A entry should be made to show the question was reviewed and answered . 2. Review of the medical record revealed Resident #4 was admitted to the facility on [DATE] with diagnoses of Chronic Obstructive Pulmonary Disease, Pneumonia, Diabetes,…

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 facility policy review, medical record review, observation, and interview, the facility failed to ensure medication parameters were monitored in accordance with professional standards of practice for 2 of 2 sampled residents (Resident #10 and #15) reviewed for medication parameters. The findings include: 1. Review of the facility policy titled, Accucheck /Diabetic Policy and Procedure, dated 2/9/2005 revealed, It is the policy of this facility to perform Accuchecks and administer insulin as ordered by the resident's physician .If blood glucose is greater than (>) 451, implement the Diabetic Therapeutic Protocol . Review of the facility policy titled, Diabetic Therapeutic Protocol, dated 3/3/2005 revealed, .Hyperglycemia [elevated blood glucose level] .If asymptomatic (alert and able to follow directions) .and blood glucose is greater than .451 implement the following .If no sliding scale is ordered for resident, notify physician for further orders . 2. Review of the medical record revealed Resident #10…

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.