Briarcliff Health Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect , exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that caused the allegation involve serious bodily injury, to the administrator of the facility and to other officials, which included the State Survey Agency, in accordance with State Law through established procedures to report to state agency for 1 of 7 Residents (Resident #66 ) reviewed for abuse and neglect. The facility failed to report the results of an unwitnessed incident to the State Survey Agency. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 4 of 6 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for ADLs. The facility did not provide scheduled showers for Resident #1, Resident #2, Resident #3, and Resident #4 These failures could place residents at risk of not receiving services/care and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 4 residents (Residents #1, Resident #2, and Resident #3) reviewed for hospice services. The facility did not ensure Resident #1, #2 and #3's hospice skilled nurse progress notes were a part of the resident records in the facility. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 beverage service areas. (ABC halls common dining area). The facility failed to ensure the large ice machine outside of the main kitchen, the ice dispenser, and the coffee and iced tea dispensers in the ABC halls common dining area were clean. These failures could place residents who consumed ice, coffee and tea from these machines, at risk of being served in unsanitary conditions and for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for 2 of 12 residents reviewed for PASRR (Residents #17 and #92). The facility failed to ensure Residents #17 and Resident #92 had accurate PASRR Level 1 Screenings indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had the right to be free of abuse for 1 of 8 residents reviewed for abuse. ( Resident #1) Resident #1 was intimidated, suffered pain and mental anguish, and forced to allow care against her will by CNA A on 3/11/24. CNA A refused to take no for an answer when Resident #1 told her she did not want to be transferred. CNA A pushed back at Resident #1's flailing hands and reached under her arms and transferred her against her will from her wheelchair to her bed. Resident #1 complained of back pain when she was transferred by CNA A. CNA A was hollering at Resident #1 and told her she was afraid for nothing. CNA A was close to Resident #1's face talking loudly in an intimidating manner. CNA A reached between Resident #1's legs to check if she was wet and the resident was begging her not to, but CNA A continued. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident was treated with dignity and respect for 1 of 8 residents reviewed for dignity. (Resident #3) Resident #3 was the victim of humiliation due to Resident #2 being allowed to urinate on him for two nights. The staff were aware of the first incident on 3/30/24 and allowed Resident #2 to continue to reside in the room with Resident #3 and a second incident occurred on 3/31/24. This failure caused a resident to be humiliated and dehumanized.

Inspectors wroteBased on interview and record review the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for 1 of 3 residents reviewed for transfer/discharge. (Resident #2) The family of Resident #2 were told to come and get him without any prior notification or discharge planning for a safe and smooth discharge. The family of Resident #2 were told the resident would be admitted to the behavioral hospital for behavior issues and then transferred to another facility but instead spent about 24 hours in the ER. These negative findings could cause a resident to have no safe and comfortable place for discharge.

Inspectors wroteBased on interview and record review the facility failed to implement an admission policy and did not disclose to a resident notice of special service limitations prior to admission for 1 of 3 residents reviewed for admission (Resident #2) Resident #2 was admitted to the facility and did not meet the facility admission criteria due to being a registered sex offender. This negative finding could have placed residents and family member at risk for possible abuse. Findings Included: Record review of Resident # 2's face sheet with no date indicated he was an [AGE] year-old male admitted to the facility on [DATE]. Some of his diagnoses were dementia, unsteadiness on feet, repeated falls, adult failure to thrive, depression with anxiety, and Parkinson's disease (disorder of the central nervous system that affects movements, often including tremors). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from neglect for 1 of 7 (Resident #1) residents reviewed for neglect. The facility failed to ensure staff performed CPR for resident #1 until emergency services arrived. The facility failed to ensure the AED was utilized when Resident #1 was found unresponsive. These failures resulted in an identification of an Immediate Jeopardy (IJ) On [DATE] at 1:40 p.m. While the IJ was removed on [DATE], the facility remained out of compliance at actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. These failures could place residents at risk for neglect by not receiving appropriate life saving measures resulting in a decline in health or death. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 2 of 7 (Resident #1 and Resident #2) residents reviewed for CPR. The facility failed to ensure staff performed CPR for resident #1 until emergency services arrived. CPR was initiated and then stopped prior to emergency services arrival. The facility failed to ensure staff utilized the AED when Resident #1 was found unresponsive. The facility failed to ensure Resident #2 advance directive was accurate. CPR was initiated on Resident #2 and stopped upon verbal confirmation by hospice agency of Resident #2's DNR. [...]

Inspectors wroteBased on interview and record review the facility did not operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 2 of 3 (LVN WWW and LVN AAA) nurses reviewed for pronouncement of death. The facility failed to ensure LVN WWW and LVN AAA worked within the scope of practice by pronouncing the death of Resident #1. This failure could place residents at risk for receiving services from nursing staff that is outside their scope of practice leading to residents not receiving proper services, decreased quality of life, and injury. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 ice machines. The facility failed to ensure the large ice machine inside the locked units was clean. These failures could place residents who consumed ice from this machine, at risk of being served in unsanitary conditions and for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care and resident census on a daily basis for 3 of 3 days (03/06/23, 03/07/23, and 03/08/23) reviewed for March 2023 nursing staffing. The facility failed to post the total number of hours worked for licensed nurses and certified nurse aides or the resident census on the staffing sheet for March 6th , 7th , and 8th of 2023. This failure could cause residents, families, and visitors to be unaware of the facility daily staffing requirements.