Briar Place Nursing

Inspectors wroteBased on interview and record review, the facility failed to ensure notification of room and roommate changes were documented, failed to ensure family was notified of the room change, and failed to ensure residents received written notice including the reason for the change before the room or roommate change. These failures affected four (R1, R5, R6, and R7) residents reviewed for residents' rights in the total sample of 7 residents.

Inspectors wroteBased on interview and record review, the facility failed to follow physician orders and failed to follow the facility community pass policy after no credible evidence of contraband was found for one (R72) resident. This failure affected one resident (R72) in a sample of 72 residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow its abuse prevention policy by not protecting a resident from financial exploitation. This failure resulted in mental anguish and helplessness among 1 of 4 residents (R2) reviewed for theft and abuse in a sample of 4.

Inspectors wroteBased on the interview and record review, the facility failed to comply with privacy and confidentiality requirements when delivering mail to residents. This applies to 1 of 4 residents (R2) reviewed for privacy and confidentiality with mail delivery in a sample of 4.

Inspectors wroteBased upon record review and interview the facility failed to follow policy procedures and failed to ensure that the advance directives care plan was correct for one of four residents (R4) reviewed for change in condition.

Inspectors wroteBased upon record review and interview the facility failed to follow policy procedures, failed to ensure that comprehensive care plans are reviewed quarterly, failed to ensure that the goal target date is within 90 days, and failed to revise an advance directive care plan (as directed) for one of four residents (R4) reviewed for change in condition.

Inspectors wroteBased on interview and record review, the facility failed to secure the physical environment (window) in R1's room and implement appropriate precautions for a resident with a history of elopement risk, high suicidal risk, high risk per criminal background/ behavioral history, and assessed as being unsafe in the community unsupervised for one resident (R1) of three residents reviewed for elopement. This failure resulted in R1 removing the stationary window brackets that prevent the window from opening in his room, jumping out of the window, and eloping through the open back gate of the facility undetected by staff. The immediate jeopardy began on 7/3/25 at 10:28 PM, when R1 removed the stationary window brackets that prevent the window from opening in his room, jumped out of the window, and eloped through the open back gate of the facility undetected by staff. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their abuse policy by failing to investigate an allegation of misappropriation of resident's fund by another resident. This failure affected two of three (R4 and R6) residents reviewed for investigating residents' allegations of misappropriation of funds.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the chillers (air conditioner units) were in operating condition and functioning properly. These failure have the potential to affect all 202 residents residing at the facility.

Inspectors wroteBased on observation, interview and record review, the facility failed to keep the facility temperature below 81 degrees Fahrenheit and failed to ensure the temperature was comfortable for one resident (R3) out of 6 residents reviewed for safe, comfortable environment. These failures have the potential to affect all 202 residents residing in the facility.

Inspectors wroteBased on interview and record review, the facility failed to document providing the bed hold policy to the resident or representative upon transfer to a local hospital, for one (R2) of three residents reviewed for bed hold policy.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide one resident (R85) with adequate supervision during a shower. This resulted in R85 experiencing a seizure which led to her arm getting stuck in the handrail causing her to fracture her humerus. Findings Include: R85 is a [AGE] year-old female who originally admitted to the facility on [DATE] and continues to reside in the facility. R85 has multiple diagnoses including but not limited to the following: Epilepsy, right humerus fracture, bipolar disorder, paranoid schizophrenia, mood disorder, anxiety, pain, and depression. Facility Reported Incident with date of 10/9/24 states in part but not limited to the following: R85 noted in shower room with right arm between shower rail and wall, R85 noted with pain, shortening, and abnormal rotation to right arm. [...]

Inspectors wroteBased on observations, interview, and record review the facility failed to follow the hand hygiene policy. This failure has a potential to affect all 216 residents currently residing in the facility.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide a clean and sanitary home-like environment for 143 residents currently residing on the facility's first and second floor units.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own pharmacy's policy on expiration dating for medications in vials by failing to date two opened vials of insulin found inside the facility's second floor storage room refrigerator, potentially affecting two residents (R51 and R130) reviewed for drug storage.

Inspectors wroteBased on observation, interviews, and record review the facility failed to follow their pain management program when they failed to accurately assess R182's pain level and to ensure R182's pain was managed in a timely manner, four days after neck surgery to repair herniated discs. This failure resulted in R182 not receiving effective pain medication while experiencing severe and unbearable pain for an extended period of time, 9/10 on a pain scale of 0-10, in addition to suffering through periods of uncontrolled anxiety as a result of the prolonged severe pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a vulnerable resident (R6) was free of physical abuse inflicted by staff. This failure resulted in R6 sustaining multiple injuries including a closed head injury and contusions (bruising) of the right thumb and forearm.

Inspectors wroteBased on interview and record review, the facility failed to provide detailed written notice 30 days prior to the discharge for one resident (R1) by failing to allow R1 to return to the facility while being accounted for on a facility issued community pass. This failure resulted in R1 not being properly discharged and being without medical care and medications for a month before getting a new primary care physician.

Inspectors wroteBased on interview and record review, the facility failed to restrict independent community access to a resident (R3) who was known to be refusing psychiatric/medically necessary medication and exhibiting active delusions and hallucinations. This failure resulted with R3 going out for a walk unsupervised and not returning to the facility. R3 was found three days later by local law enforcement, lying on the ground in the community, and taken to the emergency room where R3 was assessed with active psychosis.

Inspectors wroteBased on interview and record review the facility failed to ensure that their policies related to independent community access were not in conflict with proper discharge procedures. This failure resulted in two residents (R1 and R3) being considered discharged against medical advice while on approved day and overnight passes signed by the facility and has the potential to affect 37 residents with current access to independent community pass.

Inspectors wroteBased on interview and record review, the facility failed to effectively supervise a resident with history of drug abuse. This deficient practice affects one resident of three residents reviewed for change in condition. R28 had multiple incidents of noncompliance for bringing in contraband and R28 tested positive for cocaine once during R28's stay in the facility. R28 expired on 12/2/23 in the facility with cause of death as combined drug toxicity: Drug fentanyl Acetyl despropionyl fentanyl raised to the level of an Immediate Jeopardy. The Immediate Jeopardy began on 12/2/23 when R28 was found to be unresponsive at the bedside without breath. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on 4/12/24 at 10:18am. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its wound policy and showering protocol and provide residents with a shower and perform a skin assessment once a week. This failure affected 7 residents (R7, R10, R15-R19) out of 7 residents reviewed for showers and skin assessments.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow their physician visit policy and ensure the attending physician conducted face-to-face visit within the first 30 days of admission and/or at least once every 60 days. This affected six of six residents (R7, R15, R16, R18, R19, and R21) reviewed for physician visit.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its self-administration of medications policy and assess one resident (R17) to determine if this practice was safe prior to allowing R17 to self-administer medications out of three residents reviewed for self-administration of medications in a sample of 35.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to determine how a resident sustained bruising to the left side. This affected one of three (R21) residents reviewed for injury of unknown origin.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its abuse policy and report an injury of unknown origin to the regulatory agency. This affected one of three residents (R21) reviewed for abuse reporting.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow its abuse policy and investigate an injury of unknown origin. This affected one of three residents (R21) reviewed for abuse investigation.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow its presumed death policy and initiated CPR (cardiopulmonary resuscitation) on a resident exhibiting obvious signs of irreversible death including: R17 with the presence of rigor mortis in jaw, lividity (blood pooling) in back and legs, and absence of vital signs, and R28 with full rigor mortis throughout the body and asystole. This failure affected two residents (R17 and R28) out of four residents reviewed for acute change in condition in a sample of 35. On [DATE], R17 expired in this facility at 11:36 PM due to cardiac/respiratory arrest. On [DATE] R28 expired in this facility at 6:11AM with cause of death as combined drug toxicity: Drug fentanyl Acetyl despropionyl fentanyl.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure medication is taken when administered and accounted for. This affected one of three (R15) residents reviewed for medication. This failure resulted in medication being left at R15's bedside, and loose medication being found on the floor unaccouted for.

Inspectors wroteBased on interview and record review, the facility failed to follow its room change policy by failing to notify resident's family/POA of room changes. This failure affected one resident (R3) of one resident reviewed for room change.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff provide care to dependent residents that need assistance with Activities of Daily Living (ADLs). This failure affected four (R1, R18, R99 and R160) of five residents reviewed for ADL care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to administer pain medication per physician orders. This failure applied to two (R123 and R53) of two residents reviewed for pain management.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a secure toilet seat cover for the resident's room for four (R11, R53, R107, R126) residents and failed to provide a bed foot board for one (R41) resident reviewed for environment.

Inspectors wroteBased on interview and record review, the facility failed to manage resident's pain in accordance with the plan of care for pain management. This failure applied to one (R53) of 10 residents reviewed for nursing care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prevent a resident from developing pressure ulcer/pressure injury (PU/PI) for a resident who is totally dependent on staff for care. This failure affected one (R41) of three residents reviewed for pressure ulcers and resulted in R41 developing a facility-acquired Stage 4 pressure ulcer to his left ischium, a deep tissue injury to his left medial leg, and a new wound to his mid back.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to follow their policy and procedures for fall prevention by not providing appropriate supervision and monitoring and/or implementing care plan interventions for residents assessed to be at risk for falls and with a history of falls. These failures applied to three (R2, R52, R507) of eleven residents reviewed for accidents and resulted in R2 sustaining a chin injury, R52 sustaining a leg fracture, and R507 sustaining an eye laceration that required sutures.

Inspectors wroteBased on interviews and record reviews the facility failed to follow their policy and procedures for psychotropic drug therapy by not ensuring psychotropic medication was administered as ordered. This failure applied to one (R90) of seven residents reviewed for behavior management.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to adequately monitor a resident (R202) for adverse side effects from a prescribed psychotropic medication that resulted in the resident exhibiting frequent tremors and irregular movement to her body and hands. This failure affected one (R202) of two residents reviewed for medication side effects.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to adequately label and dispose of insulin; failed to adequately dispose of expired medications from medication cart; and failed to follow their facility policy by not properly labeling, storing and disposing of expired medications. These failures applied to three (R16, R39, and R120) of three residents reviewed during the medication storage task.

Inspectors wroteBased on interviews and record reviews, the facility failed to have adequate supervision and interventions in place to keep residents assessed to be at risk for falls, free from injury. These failures applied to two (R133 and R302) of two residents reviewed for accidents and supervision and resulted in (R133) having a fall with head injury that required three sutures and resulted in R302 having an accident which resulted in a mid collar bone fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff to meet resident needs, including timely administration of scheduled medications. This failure affected ten (R18, R35, R38, R43, R63, R88, R89, R108, R152 and R200) of ten residents reviewed for staffing and has the potential to affect all 204 residents currently in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their policies and protocols related to universal precautions by failing to properly wear personal protection equipment, failing to label isolation rooms, not properly handling linens and refuse. These failures applied to nine (R31, R40, R45, R58, R60, R61, R133, R163, and R173) residents reviewed for infection control and have the potential to affect all 204 residents currently in the facility.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an environment that was clean and homelike. This failure applied to five (R2, R5, R132, R182, R184) of five residents reviewed during the annual survey for environment.

Inspectors wroteBased on interview and record review, the facility failed to follow their Abuse Prevention Program by not conducting a complete background check (finger printing) prior to the hire of a new employee (V16 / Licensed Practical Nurse). This failure has the potential to affect the 25 residents that currently reside on the first floor high side where V16 (LPN) was assigned to work.

Inspectors wroteBased on interview and record review, the facility failed to properly investigate an alleged abuse allegation by not having a complete employee file for the subject of the investigation (V16/LPN), per their abuse protocol. This failure has the potential to affect all 25 residents that resided on the first floor high side, where V16 (LPN) is assigned to work.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received prescribed medications on time, as ordered. This failure affected ten (R18, R35, R38, R43, R63, R88, R89, R108, R152 and R200) of ten residents reviewed during the medication administration task.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their food safety policies related to ensuring that opened/left over foods were properly labeled and dated, that staff performed adequate hand hygiene, and proper infection control processes during food preparation and serving and failed to ensure that sanitizer buckets were at an appropriate level. These failures have the potential to affect all 203 residents who receive meals and dietary services from the facility kitchen.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to immediately assess and monitor a resident for intolerance to tube feeding who was experiencing ongoing diarrhea. This failure applied to one of one (R163) resident reviewed for tube feedings.

Inspectors wroteBased on interview and record review, the facility failed to ensure a psychotropic consent was completed prior to the administration of a psychotropic medication. This failure applied to one (R252) of one resident reviewed for receiving psychotropic medications.