Briar Hill Rest Home

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased on interview, record review, and policy review, the facility failed to ensure the resident's right to be free from neglect when staff failed to both assist during use of a full body lift to transfer a resident from bed to the geriatric chair, which resulted in the resident being transferred to the hospital with injuries for one (1) of (30) residents who are assessed to use a full body lift.

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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)

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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: [...]

Inspectors wroteBased 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 . [...]

Inspectors wroteBased 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.