Brittany Manor

Inspectors wroteBased on interview and record review, the facility failed to provide medication according to professional standards of practice for 2 residents (R89 and R94) of the 6 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adherence to standard infection control practices during medication administration for one Resident (R24) and failed to have an active and ongoing plan for reducing the risk of legionella and other opportunistic pathogens of premise plumbing (OPPP).

Inspectors wroteBased on interview and record review, the facility failed to ensure dignified care was provided for 1 resident (R72) of 3 residents reviewed for dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to promptly assess and treat a new skin concern for one resident (R1) of 3 residents reviewed for skin concerns.

Inspectors wroteBased on interview and record review, the facility failed to follow up with pressure ulcer wound clinic recommendations for two residents (R3 and R4) of two residents reviewed for the treatment of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate urinary catheter care for one resident (R4) of three residents reviewed for catheter care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate assessments and monitoring were implemented for 1 resident with a PICC (Peripherally Inserted Central Catheter) (R45) out of 2 residents reviewed for PICC lines.

Inspectors wroteBased on interview and record review, the facility failed to adhere to principles of antibiotic stewardship for 1 resident with a fungal infection (R24), out of 15 residents reviewed. Findings Include:Review of an admission Record reflected R24 admitted to the facility with diagnoses that included urinary tract infection, sepsis, a body mass index (BMI) of 39.0-39.9 (severe obesity), and type 2 diabetes. R24 was their own responsible party. Review of a late entry Nurse Practitioner Note dated 5/14/2026 reflected R24 had been seen due to itching to labia . No redness, discharge or burning with urination. [...]

Inspectors wroteBased on interview and record review, the facility failed to offer and maintain education of pneumococcal immunizations for two Residents (R2 and R18) of five residents reviewed for their status of pneumococcal vaccinations.

Inspectors wroteThis citation pertains to intakes #: 2808141, 2749047, and 2977070Based on interview and record review, the facility failed to 1.) ensure comprehensive nursing assessments were completed and 2.) identify and notify the provider of a change in condition for 2 residents (Resident #7 and #8) out of 3 residents reviewed for quality of care resulting in a delay in treatment, the worsening of symptoms, and hospitalization.

Inspectors wroteThis citation refers to Intake 2748888. Based on interview and record review, the facility failed to maintain complete and accurate medical records for 1 of 8 sampled residents (R4).

Inspectors wroteThis citation pertains to intake # 2656241 and #2658212. Based on interview and record review, the facility failed to protect the resident's right to be free from physical abuse by a staff person, for two of three residents (Resident #100 and Resident #101) reviewed for abuse, resulting in the need for emergency medical attention and admission to the hospital for R100.

Inspectors wroteThis citation pertains to complaint #2626994. Based on interview and record review, the facility failed to implement policies and procedures for ensuring reporting of a reasonable suspicion of a crime in accordance with section 1150B of the Social Securities Act regarding reportable incidents for 2 residents (R101 and R102) of 3 residents reviewed for abuse.

Inspectors wroteBased on interview and record review, the facility failed to 1.) accurately document administration of controlled substances and 2.) ensure narcotic medications were administered following the physician order for 4 residents (Residents #23, #74, #84, and #10), reviewed for controlled substances, resulting in medication errors.

Inspectors wroteBased on interview and record review the facility failed to maintain a complete and accurate medical record for 5 residents (R2, R69, R73, R76 & R88) out of 19 residents reviewed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to proved dignified care and services for two facility residents (R10 and R34).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food and beverages were enjoyable for three facility Residents (R34, R59, and R41) out of 19 residents reviewed.

Inspectors wroteBased on interview and record review, the facility failed to promptly identify a change in condition and act upon those changes for 1 resident (R4) out of 4 residents reviewed for quality of care, resulting in R4 experiencing unnecessary pain, a delay in evaluation and surgical intervention for a femur fracture.

Inspectors wroteThis citation pertains to intake # MI00149549 Based on observation, interview, and record review, the facility failed to ensure a resident was transferred following care planned interventions and standards of practice for 1 resident (Resident #1) out of 4 residents reviewed for accidents and safety, resulting in R1 sustaining a preventable fall with facial bruising and lacerations requiring hospital treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to record, track, and respond to resident concerns/grievances for two residents (#1, #232) and two residents in confidential resident council meeting resulting in the potential of resident concerns not being addressed and the potential for care needs unmeet. Findings Included: Resident #232 (R232) Review of the medical record revealed R232 was admitted to the facility 03/11/2024 with diagnoses that included chronic obstructive pulmonary disease (COPD), nicotine dependence, hypokalemia (low potassium) hypocalcemia (low calcium), muscle weakness, morbid obesity, gastro-esophageal reflux, ischemic cardiomyopathy (heart damage), hyperlipidemia (high fat content in blood), atherosclerotic heart disease (damage to major blood vessels in the heart), type 2 diabetes, hypertension, and congestive heart failure (CHF). [...]

Inspectors wroteDuring record review and interview the facility failed to ensure the advanced directives, Do Not Resuscitate documentation was completed with two signatures for one (R#48) of one resident reviewed for completed advanced directives. Findings Include. Resident #48 (R48) Record review revealed R48's Do Not Resuscitate (DNR) was signed on 03/07/24 but did not have 2 witness signatures as required. During an interview on 04/03/24 at 12:17 PM, Social Worker (SW) S stated they usually have 2 signatures, his does not. Writer asked if she would expect to see two signatures for witnesses? SW S stated yes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that written notification required for facility-initiated transfers were provided to residents or resident representatives for 2 (Resident #24 and #38) of 2 residents reviewed for hospitalization, resulting in the potential of residents and/or representatives being un-informed of the reason for transfer and their appeal rights.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the bed hold policy was provided for 2 (Resident #24 and #38) of 2 residents reviewed for hospital transfer, resulting in the potential for resident's and/or representatives to be uninformed of the facility's bed hold policy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the Minimum Data Set (MDS) assessment was accurately coded for one (Resident #3) of 18 residents reviewed for MDS, resulting in the potential for inaccurate care plans and unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to assure PASRR assessment was completed timely for one of one reviewed for PASRR (Resident #61), resulting in the potential for this resident not maintaining or achieving their highest practicable psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to revise the Care Plan for two (Resident #1 and #66) of 18 reviewed for Care Plans, resulting in inaccurate Care Plans and the potential for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide assistance with activities of daily living (ADLs) for 1 (Resident #38) of 1 resident reviewed for ADLs, resulting in unmet care needs and the potential for a decline in emotional and physical health.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an assessment/intervention for bowel constipation for one resident (#236) of one resident reviewed for constipation. Findings Included: Resident #236 (R236) Review of the medical record revealed R236 was admitted to the facility 03/23/2024, discharged 03/202024 and readmitted [DATE] with diagnoses that included metabolic encephalopathy (global cerebral dysfunction), hyponatremia (low sodium) , pneumonia, breast cancer, urinary tract infection, muscle wasting, Parkinson's disease, hypertension, macular degeneration, anxiety, hypothyroidism (low thyroid hormone), neuropathy(nerve damage/pain), and gastro-esophageal reflux. The most recent Minimum Date Set (MDS) with and Assessment Reference Date (ARD) of 03/26/2024, revealed a Brief Interview for Mental Status (BIMS) of 14 (cognitively intact) out of 15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to administer pain medication in a timely manner for one resident (#77) of one resident reviewed for timely administration of pain medication. Findings Included: Resident #77 (R77) Review of the medical record revealed R77 was admitted to the facility 02/23/2024 with diagnoses that included nontraumatic intracerebral hemorrhage (stroke), chronic pain, cerebral infarction (stroke), hemiplegia (paralysis) on right dominate side, weakness, dorsalgia (back pain), hypertension, hyperlipidemia (high fat content in blood), anxiety, asthma, bipolar disorder, post-traumatic stress disorder, depression, arthritis, chronic obstructive pulmonary disease (COPD), and muscle wasting. [...]