Briarfield Manor

Inspectors wroteBased on observation, record review and interview, the facility did not consistently ensure narcotic medication was properly reconciled. This had the potential to affect 17 residents (Residents #1, #11, #17, #23, #27, #30, #45, #46, #47, #48, #49, #51, #54, #58, #60, #69 and #75) of 17 residents who receive narcotic medications from the facility including . The facility census was 78.

Inspectors wroteBased on record review and interview, the facility failed to ensure Resident #81 was free from significant medication error. This affected one resident (Resident #81) of five resident records reviewed for medication administration. The facility census was 78.

Inspectors wroteBased on record review and interview, the facility failed to ensure medication refrigerators were maintained at an appropriate temperature. This had the potential to affect all residents in the facility. The facility census was 78.

Inspectors wroteBased on record review, staff interview, review of personnel records and facility policy review, the facility failed to ensure the integrity and security of controlled substances and failed to maintain accurate narcotic destruction records as required, when Licensed Practical Nurse (LPN) #694 forged LPN #677's signature on a controlled drug record for Residents #483. This affected one resident (#483) of three residents reviewed for controlled medications. The facility census was 68.

Inspectors wroteBased on record reviews, fall investigation reviews, interviews and facility policy review, the facility failed to ensure falls were thoroughly investigated for Residents #17 and #72. This affected two residents (#17 and #72) of three residents reviewed for falls. The facility census was 70.

Inspectors wroteBased on observation, record review, facility policy review, and interview, the facility failed to develop and implement a comprehensive, individualized and effective pain management program for Resident #273 and Resident #66. This affected two residents (#273 and #66) of two residents reviewed for pain. The facility census was 67. Actual harm occurred beginning on 02/20/25 when the facility failed to ensure narcotic (pain) medication (that Resident #273 had been receiving prior to admission) was ordered and provided at the time of and timely following admission to manage the resident's pain. On 02/21/25 and 02/22/25 the resident reported constant pain, all over that limited his functional abilities during therapy evaluations. On 02/23/25 the resident refused therapy due to pain and was teary-eyed. On 02/24/25 at 10:01 A.M., Resident #273 stated he was in constant pain all over. [...]

Inspectors wroteBased on observations, interviews, record review, and review of the facility menu spreadsheets and facility policy, the facility failed to follow the menu for dinner on 02/25/25 for all residents on a regular texture and mechanical soft diet. This affected all residents receiving meals from the kitchen excluding 11 residents (#10, #11, #13, #21, #28, #40, #43, #57, #59, #61, and #225) the facility identified as receiving a pureed diet, one resident (#52) who received nothing by mouth (NPO) and Resident #22 who the facility identified as having a special preference noted to receive bread and margarine at the dinner meal. The facility census was 67.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure tube feeding and intravenous (IV) poles were clean and sanitary. This affected five residents (#13, #43, #52, #57 and #226) of five residents observed for tube feeding and IV poles. The facility census was 67.

Inspectors wroteBased on observation, interviews, record review, review of the facility Fall and Winter menus, and review of the facility policy, the facility failed to ensure there was a nutritionally equivalent alternate for residents who disliked Brussel sprouts. This affected nine residents (#2, #8, #15, #32, #45, #59, #272, #276, and #278) the facility identified as having a dislike of Brussel Sprouts out of 66 residents receiving meals from the kitchen. The facility identified one resident (#52) as receiving nothing by mouth (NPO). The facility census was 67.

Inspectors wroteBased on observation, interview and record review, the facility failed to notify Resident #32's representative of a new skin impairment. This affected one resident (#32) of three residents reviewed for changes in condition. The facility census was 67.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure Resident's #52 and #66's care planned interventions for grooming were implemented. This affected two residents ( #52 and #66) of three residents reviewed for grooming. The facility census was 67.

Inspectors wroteBased on observation, interview, record review and facility policy review, the facility failed to ensure treatments were administered according to physician orders for Residents #40 and #58. This affected two residents (#40 and #58) of three residents reviewed for physician orders. The facility failed to adequately document abnormal vital signs for Resident #57 exhibiting a change in condition resulting in hospitalization. This affected one resident (#57) of three residents reviewed for change in condition. The facility census was 67.

Inspectors wroteBased on observation, medical record review and staff interviews, the facility failed to ensure incontinence care was provided in a timely manner for Resident #67. This affected one resident (#67) of two residents reviewed for incontinence care. The facility census was 67.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to accurately and consistently monitor and record a physician ordered fluid restriction for Resident #58 and #29. This affected two residents (#29 and #58) out of nine residents reviewed for nutrition. The facility census was 67.

Inspectors wroteBased on record review, interviews, review of the long term care facility compliance agreement, and review of communication sheets from dialysis, the facility failed to ensure communication between the facility and the dialysis center was being received after every dialysis treatment as required for Resident #31. This affected one resident (#31) out of one resident reviewed for dialysis. The facility identified Resident #31 as the only resident receiving dialysis. The facility census was 67.

Inspectors wroteBased on observation, interview, record review, review of the Centers for Disease control and Prevention (CDC) guidelines and facility policy review, the facility failed to ensure infection control logs were accurate and appropriate isolation precautions were in place for Resident #57. This affected one resident (#57) of three residents reviewed for infection control. The facility census was 67.

Inspectors wroteBased on record review, facility policy and procedure review and interview the facility failed to maintain sufficient levels of staff to meet the total care needs of all residents. This affected three residents (#10, #17 and #46) and had the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on observation, record review, facility policy and procedure review, Centers for Disease Control (CDC) guidance and interview the facility failed to maintain proper infection control practices during blood glucose monitoring and for residents in quarantine and/or isolation for COVID-19 to decrease the risk of spreading infection, including COVID-19. This affected one resident (#58) of two residents observed for blood glucose monitoring, six residents (#4, #40, #43, #12, #211 and #212) reviewed related to COVID-19 and had the potential to affect all 65 residents residing in the facility.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure all medications were properly stored and failed to ensure insulin pens were dated when opened. This affected five residents (#19, #23, #46, #53 and #58) of eight residents reviewed for medication administration and/or involved in observations of three medication carts and one medication room. The facility census was 65.

Inspectors wroteBased on record review and interview the facility failed to ensure residents were assisted with showers as per their preference. This affected three residents (#10, #17, #46) of 18 residents interviewed regarding choices and showers.

Inspectors wroteBased on medical record review and interview the facility failed to ensure residents were invited to participate in meetings discussing and developing their plan of care. This affected three residents (#10, #41 and #45) of 18 residents who were interviewed regarding participation in development of their plan of care.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to ensure Resident #41 and #45, who required staff assistance with activity of daily living care received timely and adequate oral hygiene and/or nail care. This affected two residents (#41 and #45) of five residents reviewed for activities of daily living.

Inspectors wroteBased on record review and interview the facility failed to ensure Resident #10, who exhibited limited range of motion (ROM) received services to increase and/or maintain range of motion. This affected one resident (#10) of 25 residents reviewed and/or interviewed regarding range of motion.

Inspectors wroteBased on observation, record review, facility policy and procedure review and interview the facility failed to maintain a medication error rate of less than five percent. The medication error rate was calculated to be 6.25% and included two medication errors of 32 medication administration opportunities. This affected two residents (#38 and #58) of seven residents observed for medication administration.

Inspectors wroteBased on closed record review and interview the facility failed to promptly notify the physician or nurse practitioner of laboratory results outside the clinical reference range for Resident #61. This affected one resident (#61) of five residents reviewed for unnecessary medication use.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure resident medical records were complete and accurate. This affected three (#41, #45 and #62) of 21 residents whose medical records were reviewed.

Inspectors wroteBased on review of Quality Assessment and Assurance (QAA) meeting attendance sheets and interview the facility failed to ensure the required members of the QAA committee participated in meetings to address QAA activities. This had the potential to affect all 65 residents.

Inspectors wroteBased on review of personnel files and interview, the facility failed to ensure prospective new employees were checked with the nurse aide registry to determine if they had findings of abuse, neglect, exploitation, or misappropriation reported to the nurse aide registry prior to their application and hire at the facility. This had the potential to affect all 95 facility residents.

Inspectors wroteBased on review of the facility assessment and interview, the facility failed to conduct, document, and update a comprehensive facility assessment. This had the potential to affect all 93 residents.

Inspectors wroteBased on record review and interview, the facility failed to ensure Residents #28, #30, #40, #87, #106, and #317 were notified in writing the reason for the discharge to the hospital in an easily understood language, and failed to notify the ombudsman's office of the residents discharge to the hospital. This finding affected six (Residents #28, #30, #40, #87, #106, and #317) of six residents reviewed for hospitalization. The facility census was 95 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store and label medications according to accepted professional standards. This affected two (Residents #104 and #12) of four residents who received medications administered by nurses at the facility. This also had the potential to affect 27 residents who received medications held in medication storage cart #2. The facility census was 95 residents.

Inspectors wroteBased on review of resident funds accounts and interview, the facility failed to deposit the entirety of a resident's funds into her account. This affected one (Resident #24) of six residents whose accounts were reviewed. The facility census was 95 residents.

Inspectors wroteBased on review of resident fund accounts and interview, the facility failed to notify a resident or his guardian when the amount in his account reached $200 less than the limit permitted for Medicaid recipients. This affected one (Resident #45) of six residents whose accounts were reviewed. The facility census was 95 residents.

Inspectors wroteBased on medical record review and interview, the facility failed to provide comprehensive assessments related to medical diagnoses and conditions for one (Resident #157) of 29 residents whose records were reviewed for assessments. The facility census was 95 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure the Narcotic Control Records accurately reflected the actual narcotic count following administration of resident narcotics. This affected one (Resident #39) of fourteen residents who received narcotics from medication cart #2. The facility census was 95 residents.

Inspectors wroteBased on observation, record review, and interview, the facility failed to maintain the appropriate infection control procedures during Resident #28's medication administration. This finding affected one (Resident #28) of five residents observed for medication administration. The facility census was 95 residents.