Briarwood Nursing and Rehabilitation Center, Inc

Inspectors wroteBased on observations and interviews, the facility failed to ensure garbage and refuse were disposed of properly for 2 of 2 dumpsters observed.

Inspectors wroteBased on observation, record review, interview, and facility policy review, the facility failed to ensure a catheter bag did not touch the floor for 1 (Resident #42) of 1 resident during 2 of 2 observations to prevent hospital readmissions and the risk of infection in a resident with a suprapubic catheter and history of Urinary Tract Infections (UTI).

Inspectors wroteBased on observation, record review, interview, and Centers for Disease Control guidance, the facility failed to ensure staff followed Enhanced Barrier Precautions (EBP) during wound care. Specifically, the Treatment Nurse failed to wear a gown when performing wound care for 1 sampled (Resident #7) resident during 1 of 1 observation to prevent cross contamination and the risk for infection.

Inspectors wroteBased on observations, record reviews and interviews, it was determined that the facility failed to immediately report to the Office of Long-Term Care (OLTC), an allegation of verbal and physical abuse for one (Resident #317) of one resident reviewed for abuse and neglect.

Inspectors wroteBased on observation, record review and interviews, the facility failed to ensure 2 of 2 refrigerators and freezers used for the storage of food items was clean and sanitary; food items stored in the refrigerator and freezers were labeled and dated to prevent potential cross-contamination and minimize the potential for food borne illness; the main facility kitchen failed to provide open dates on food items; expired food items were properly disposed of; open food items were not in sealed containers or had open dates. These failed practices had the potential to harm 99 residents. On 03/04/24 at 12:29 PM, in the 500-hall dining room, Surveyor observed 9 cups of water, 3 cups of flavored drink, and 3 cups of tea, on the dining hall cart without covers. The straws placed in the drinks were not covered. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete discharge Minimum Data Set (MDS) assessments in a timely manner for 7 (Resident #9, #23, #32, #36, #54, #77 and #97) sampled residents, and failed to complete admission MDS assessments in a timely manner for 2 (Resident #46 and #274) sampled residents. The failed practice had the potential to affect 135 residents who discharged home in the past 120 days and 124 residents admitted in the last 120 days.

Inspectors wroteBased on interview and record review, the facility failed to ensure that Minimum Data Set (MDS) assessments were completed accurately to reflect that a resident was receiving anticoagulant medication for 1(Resident #17) sampled resident. The failed practice had the potential to affect 8 (Residents #68, #99, $73, #56, #31, #323, #4 and #116) sampled residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop care plans to address one resident with a pressure ulcer for 1(Resident #99) one resident receiving a tube feeding (Resident #173) 2 residents receiving anticoagulant medications (Resident #111 and 173), and one resident receiving antianxiety and antidepressant medications (Resident #173) to ensure appropriate coordination of care. This failed practice had the potential to affect 6 residents that had pressure ulcers, 2 residents that had tube feedings, 25 residents that received anticoagulant medications, 18 residents that received antianxiety medications and 48 residents that received antidepressant medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that oral care was provided for 1 (Resident #96) of 4 (Resident #11, #21, #91, #96) sampled residents with the potential to affect 23 residents on 400 hall dependent on staff for receiving oral care and the facility failed to ensure that 1 (Resident #116) of 2 sampled Residents (#116, #324) was cleaned in a sanitary manner to promote good body hygiene. This failed practice had the potential to cause skin breakdown, infection, and poor hygiene for 4 Residents on 500 hall who were dependent on staff for bathing assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that oxygen tubing was dated and stored correctly for 2 (Resident #46 and #275) sampled residents to reduce the potential for respiratory complications. This failed practice had the potential to affect 11 residents that had physicians for oxygen therapy.

Inspectors wroteBased on observation, record review and interview, the facility failed to properly store and maintain a denture cup and toothbrush in a safe, clean, sanitary manner to prevent the risk of cross contamination for 1 (Resident #96) of 4 sampled (Resident 11, R#21, R#91, R#96) with the potential to affect 23 residents on 400 hall dependent on staff for receiving oral care for personal hygiene. The facility failed to ensure that staff used proper hand hygiene while assisting Residents (#22, #30, #59, #86, #275) with meal service and while aiding with bed bath for Resident #116. The facility also failed to ensure that staff refrained from placing items used during care on the floor. This failed practice had the potential to cause the spread of infectious disease throughout the facility.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the resident environment was free from hazards by leaving the storage room door unsecured, allowing residents access to supplies that are not for human consumption. This failed practice had the possibility of affecting 6 (Residents #43, #61, #323, #324, #326, #327) sampled residents with a Brief Interview for Mental status score (BIMS) of 13 or below out of 29 residents the reside on 500 Hall. The facility failed to ensure a mechanical lift was in safe operational condition to prevent possible injury for 1 (Resident #11) of 2 sampled residents (Residents #11 and #21) with the potential to effect 6 residents on 400 hall requiring mechanical lift assistance.

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure 1 (Resident #11) received double portions as part of a dietary intervention to prevent weight loss and malnutrition for 1 of 3 residents receiving double portions.

Inspectors wroteBased on record review and interview, the facility failed to review and revise care plans and reassess the effectiveness of interventions to meet resident needs for 1 (Resident #2) of 3 sampled residents. This failed practice had the potential to affect 8 residents that had falls in the last 3 months.

Inspectors wroteBased on observation and interview, the facility failed to ensure the ice machine in the kitchenette on the 300 Hall and the 400 Hall was maintained in a clean and sanitary condition and expired food was not available for resident use in the kitchenette; and failed to ensure dietary staff washed their hands before handling clean equipment or food items to prevent potential food borne illness for residents who received meals from 1 of 1 kitchen. These failed practices had the potential to affect 102 residents who received meals from the kitchen (total census: 103) as documented on a list provided by Dietary Employee (DE) #1.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure a medication cart was kept locked when unattended to prevent the potential loss of medication and/or access by residents who were able to ambulate with or without assistance. This failed practice had the potential to affect 14 (Residents #4, #10, #23, #28, #32, #33, #37, #38, #39, #42, #45, #60, #66 and #67) sampled residents who were mobile and would be able to access the unsecured cart on 300/400 hall as documented on a list provided by the Director of Nursing (DON) on 12/9/22 at 9:28 AM.