Briarwood at Timber Ridge

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure food was stored and prepared in accordance with professional standards of safety. The failure to ensure: (1) open foods were labeled and dated, (2) kitchen fan and ice machines were monitored and cleaned, and (3) kitchen garbage/trash receptacles were covered as required placed residents at risk for ingesting expired and/or contaminated food and the development of food-borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure essential equipment including the dishwasher, walk-in refrigerator, and freezer thermostat (a device that regulated a heating or cooling system to maintain a set temperature) located in the main central kitchen were maintained and kept in safe operating conditions. These failures placed the residents at risk for infection with using improperly sanitized dishes and utensils during meals, consuming foods stored in unsafe temperatures, and the development of foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, implement and/or ensure residents' comprehensive care plans accurately reflected care needs for 2 of 12 (Residents 26 & 15) residents reviewed for care planning. These failures placed residents at risk for unidentified and/or unmet care needs, medical complications and a diminished quality of life.

Inspectors wroteBased on observations, interview, and record review the facility failed to ensure Care Plans (CPs) were updated and/or revised as needed to reflect person-centered care for 3 (Resident 3, 14, & 6) of 12 residents whose CPs were reviewed. These failures left residents at risk for inappropriate care, unmet care needs, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure non-pharmaceutical interventions were in place, pain medications had parameters for residents receiving multiple pain medications, physician's orders were clarified, and staff followed post dialysis orders for 3 (Residents 8, 3 & 18) of 12 residents whose orders were reviewed. These failures placed residents at risk for ineffective treatments, medication errors, and delayed treatments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were dependent on staff for assistance with Activities of Daily Living (ADLs) received the assistance they required for 3 (Residents 14, 26, & 15) of 3 residents and 1 (Resident 3) supplemental resident reviewed for assistance with ADLs. The failure to provide assistance with putting on compression stockings, eating assistance, and grooming/personal hygiene left residents at risk for embarrassment, poor hygiene, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 3 (Resident 5, 8, & 7) of 12 residents reviewed received the necessary care and services in accordance with professional standards of practice. The facility failed to ensure residents with diabetes (disease in which the body fails to control blood sugar levels) received appropriate monitoring and had orders in place for emergent changes in blood sugar levels for 1 (Resident 5) of 1 diabetic residents, failed to implement skin preventative measures for 1 (Resident 8) of 12 residents reviewed, and failed to follow the facility bowel protocol for 1 (Resident 7) of 12 residents reviewed. These failures placed all residents at risk for unmet care needs, uncontrolled diabetes, skin breakdown, prolonged constipation, pain, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure a licensed pharmacist's monthly Medication Regimen Reviews (MRRs) were completed monthly and recommendations were reviewed and acted upon for 2 (Resident 3 & 5) of 5 residents reviewed for unnecessary medications. This failure placed all residents at risk for delays in necessary medication changes and at risk for adverse side effects.

Inspectors wroteBased on interview and record review, the facility failed to maintain complete and accurate medical records for 2 (Residents 34 & 3) of 12 residents whose records were reviewed. Staff failure to include interdisciplinary team notes from behavior meetings including physician documentation regarding Gradual Dose Reduction (GDR) decisions placed residents at risk for unmet care needs and risk for receiving unnecessary psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which residents received required written notices at the time of transfer/discharge, or as soon as practicable for 2 (Residents 43 & 30) of 4 residents reviewed for hospitalizations. Failure to ensure written notification to the resident and/or the resident's representative of the reasons for the discharge in writing and in a language and manner they understood, placed residents at risk for a discharge that was not in alignment with the resident's stated goals for care and preferences.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 5 of 12 sample residents (Residents 33, 5, 26, 29, & 34) reviewed for care and services received the necessary care and services they required in accordance with professional standards of practice. The facility failed to monitor residents taking anticoagulant medications (Residents 33, 5, 26, &, 29) and assess, monitor, and apply compression stockings to residents with edema (Resident 34). These failures placed residents at risk for delays in treatment, potential declines in health, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment was free of accident hazards for 2 (Resident 7 & 26) of 12 sample residents. The failure to ensure resident bathroom door chime alarms were activated (Residents 7 & 26), ensure a maintenance cart containing tools and chemicals was supervised in resident common areas, and ensure kitchen pantry doors and storage rooms remained closed and/or locked, placed residents at risk for accidents, injury, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and/or implement a comprehensive Care Plan (CP) for 3 of 12 sampled residents (Residents 34, 7, & 33) whose comprehensive CPs were reviewed. The failure to develop comprehensive, individualized CPs with resident-specific goals and/or interventions placed residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure: physician's orders were followed for 1 (Resident 34); medications were administered within ordered parameters for 1 (Resident 38); and physician orders were clarified as needed for 1 (Resident 96) of 12 sample residents reviewed. These failures placed residents at risk for medication errors, delayed treatment, and adverse outcomes.

Inspectors wroteBased on observations and interview, the facility failed to ensure the Chlorine bleach test strips and QUAT test strips (Quaternary test used to verify the concentration level of sanitizers) were current (not expired) in the main kitchen and Health Center kitchen. This failure prevented kitchen staff from accurately monitoring cleaning solutions used to maintain kitchen counter and equipment sanitized.

Inspectors wroteBased on interview and record review, the facility failed to ensure a system by which the Office of the State Long-Term Care Ombudsman (LTCO, an advocacy group for individuals residing in nursing homes) received required resident discharge/transfer information for 3 (Residents 35, 36, & 141) of 3 residents reviewed for hospitalization. Failure to ensure required notification was completed, prevented the LTCO the opportunity to educate residents and advocate for them regarding the discharge process.

Inspectors wroteBased on interview and record review, the facility failed to establish an infection prevention and control program that included developing an antibiotic stewardship program to promote appropriate use of antibiotics and reduce the risk of unnecessary antibiotic use for 4 (Resident 19, 243, 38 & 141) of 12 residents reviewed for unnecessary antibiotics and 3 (May 2023, June 2023, & July 2023) of 3 months of infection control documents reviewed. This failure placed residents at risk for potential adverse outcomes, associated with the inappropriate/unnecessary use of antibiotics.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Physician's Orders (POs) were followed for 3 of 13 sample residents (Residents 8, 6 & 35), or clarified for 2 of 13 sample residents (Residents 35 and 141) whose care was reviewed. These failures left residents at risk for not receiving the care they were ordered, and other negative health outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure new skin issues were identified, assessed, or treated for 1 of 3 residents (Resident 11) reviewed for non-pressure skin and failed to ensure treatments were provided as ordered for 2 of 2 residents (Residents 35 & 29) reviewed for edema (fluid retention that causes swelling). These failures placed residents at risk for discomfort, untreated skin impairments, and other negative health outcomes.