Brown Memorial Home Inc

Inspectors wroteBased on record review, staff interviews, review of hospital records, review of orthopedic notes and review of facility policy, the facility failed to ensure the hallways were maintained free from accident hazards to prevent falls and failed to ensure the cause of falls were investigated. Actual harm occurred on 01/12/26 when a housekeeping employee placed a bag of garbage on the hallway floor. Resident #44 stumbled over the edge of the bag and fell to the floor, resulting in pain and a comminuted intra-articular right distal radius fracture which required surgical intervention. This affected one (Resident #44) out of the three residents reviewed for falls. The facility census was 37.

Inspectors wroteBased on resident record review, staff interviews, and review of facility policy, the facility failed to ensure a resident received the correct dose of medication as ordered by the physician. This affected one resident (#44) out of the three residents reviewed for medication administration. The facility census was 37.

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to adequately monitor skin issues/bruising for residents know to have skin alterations. This affected one (Resident #17) of three residents reviewed for skin alterations. The census was 33. Findings Include:Resident #17 was initially admitted to the facility for respite care on 07/07/25. Her diagnoses were Alzheimer's disease, dementia, amnesia, visual hallucinations, chronic fatigue, nonrheumatic mitral valve insufficiency, and encounter for palliative care. Review of her minimum data set (MDS) assessment, dated 11/18/25, revealed she had a severe cognitive impairment. Review of Resident #17 progress notes, dated 12/04/25, revealed hospice shower aid came to the facility nurse and stated she noted some bruising and swelling on Resident #17's lower left extremity (LLE). [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to ensure gradual dose reduction (GDR) pharmacy recommendations were completed as required. This affected one (Resident #20) of five residents reviewed for unnecessary medications. The census was 33. Resident #20 was admitted to the facility on [DATE]. Her diagnoses were gastro-esophageal reflux disease, emphysema, hyperlipidemia, morbid obesity, major depressive disorder, congestive heart failure, osteoarthritis, Type II Diabetes, chronic obstructive pulmonary disease, fibromyalgia, obstructive sleep apnea, hypertension, vitamin D deficiency, and history of falling. Review of her minimum data set (MDS) assessment, dated 09/14/25, revealed she was cognitively intact. Review of Resident #20's physician orders found the following medications ordered/administered and the dates in which they were initiated: [...]

Inspectors wroteBased on medical record review and staff interview, the facility failed to monitor the use of blood pressure medication appropriately. This affected two (Residents #11 and #5) of five residents reviewed for unnecessary medications. The census was 33. Findings Include: 1. Resident #11 was admitted to the facility on [DATE]. Her diagnoses were other long term drug therapy, anxiety disorder, Alzheimer's disease, dementia, repeated falls, hyperlipidemia, orthostatic hypotension, personal history of other diseases, visual hallucinations, cardiac murmur, restless leg syndrome, osteoporosis, neurocognitive disorder with Lewy bodies, and Parkinson's disease. Review of her minimum data set (MDS) assessment, dated 09/06/25, revealed she was cognitively intact. [...]

Inspectors wroteBased on observation and staff interview, the facility failed to ensure shower room exhaust fans were maintained in good and working order. This had the potential to affect all 33 residents identified by the facility as using the shower rooms. The facility census was 33.

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to appropriately date opened food items in the refrigerator and freezer. The deficient practice had the potential to affect all 39 residents who resided in the facility. The facility did not identify any residents with a physician ordered nothing by mouth (NPO) diet. Findings Include: Observations completed during the initial tour of the kitchen on 09/03/24 at 10:20 A.M. with Dietary Manager (DM) #106 revealed the following items in the refrigerator had been opened and not dated: [...]

Inspectors wroteBased on record review, review of the facility's beneficiary notice list and notices, staff interview, and facility policy review, the facility failed to provide an Advanced Beneficiary Notice (ABN) to one resident (Resident #141) when he was discharged from Medicare part A services and remained in the facility. The deficient practice affected one resident (Resident #141) of one reviewed for beneficiary notices. The facility census was 39. Findings Include: Review of the closed record for former Resident #141 revealed an original admission date on 01/08/24, readmission dates on 04/05/24 and 06/30/24, and a discharge date on 07/13/24. [...]

Inspectors wroteBased on staff interview and record review the facility failed to document a resident transfer in the medical record when Resident #23 was transferred to the hospital for a change in condition. This affected one (Resident #23) of three Residents reviewed for hospitalization. The facility census was 39.

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to notify the local Ombudsman when two residents (Residents #35 and #23) were transferred out of the facility and/or discharged from the facility. The deficient practice affected two residents (Residents #35 and #23) of four reviewed for hospitalizations and discharge. The facility census was 39. Findings Include: Review of the medical record for Resident #35 revealed and initial admission date on 08/08/23 and a readmission date on 04/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, and progressive systemic sclerosis. Review of the clinical census for Resident #35 revealed the resident was hospitalized on [DATE] and 06/24/24. [...]

Inspectors wroteBased on record review, staff interview, review of bed hold notices, and facility policy review, the facility failed to notify two residents (Residents #35 and #23) of the number of bed hold days each resident had remaining upon being transferred to the hospital from the facility. The deficient practice affected two residents (Residents #35 and #23) of three reviewed for hospitalizations. The facility census was 39. Findings Include: Review of the medical record for Resident #35 revealed and initial admission date on 08/08/23 and a readmission date on 04/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, and progressive systemic sclerosis. Review of the clinical census for Resident #35 revealed the resident was hospitalized on [DATE] and 06/24/24. [...]

Inspectors wroteBased on staff interview and record review the facility failed to update the Preadmission Screening Resident Review (PASRR) documents when a resident received a new mental health diagnosis. This affected two (Resident #10, and #34) of four residents reviewed for PASRR. The facility census was 39.

Inspectors wroteBased on medical record review and staff interview, the facility failed to revise care plans when significant changes in the resident's condition occurred. This affected one (Resident #34) of 15 resident care plans reviewed. The census was 39. Findings Include: Resident #34 was admitted to the facility on [DATE]. Her diagnoses were cervicalgia, anxiety disorder, schizoaffective disorder, chronic obstructive pulmonary disorder, bipolar disorder, hyperlipidemia, drug induced subacute dyskinesia, hypertension, osteoarthritis, and personal history of irradiation. Review of her Minimum Data Set (MDS) assessment, dated 06/01/24, revealed she was cognitively intact. Review of Resident #34's current physician orders revealed she was not on hospice care at that time. Review of her previous/discontinued physician orders found she was discharged from hospice care on 02/23/24. [...]

Inspectors wroteBased on observation, staff interview, and resident record review, the facility failed to ensure the care planned assistance devices were properly placed to prevent falls for one (Resident #89) of three reviewed for accident hazards. The census was 39. Findings Include: Review of the medical record for Resident #89 on 09/03/24 at 9:58 A.M. revealed an admission date of 09/01/24 with a diagnosis of atherosclerotic heart disease of native coronary artery. Review of a skilled nurse's note dated 09/01/24 at 10:09 P.M. revealed Resident #89 had a history of falls with multiple falls within the last six months. Review of the baseline careplan dated 09/01/24 at 10:14 P.M. revealed documented fall interventions including: Non-skid footwear, parameter mattress, bed in low position, and mattress to floor. Review of a nurse's note dated 09/02/24 at 5:35 A.M. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to ensure Bilevel Positive Airway Pressure (BiPAP) (a machine that helps to push air into your lungs) settings were included in the physician order for one resident (Resident #35). The deficient practice affected one resident (Resident #35) of one reviewed for respiratory care. The facility census was 39. Findings Include: Review of the medical record for Resident #35 revealed and initial admission date on 08/08/23 and a readmission date on 04/23/24. Medical diagnoses included congestive heart failure, chronic obstructive pulmonary disease, secondary pulmonary arterial hypertension, and progressive systemic sclerosis. [...]

Inspectors wroteBased on medical record review, staff interview, and facility policy review, the facility failed to obtain proper parameters for as needed pain medications. This affected two (Residents #34 and #29) of five residents reviewed for unnecessary medications. The census was 39. Findings Include: 1. Resident #34 was admitted to the facility on [DATE]. Her diagnoses were cervicalgia, anxiety disorder, schizoaffective disorder, chronic obstructive pulmonary disorder, bipolar disorder, hyperlipidemia, drug induced subacute dyskinesia, hypertension, osteoarthritis, and personal history of irradiation. Review of her Minimum Data Set (MDS) assessment, dated 06/01/24, revealed she was cognitively intact. [...]

Inspectors wroteBased on record review, staff interview, and facility policy review, the facility failed to administer blood pressure medication as ordered to one resident (Resident #29). The deficient practice affected one resident (Resident #29) of five reviewed for unnecessary medications. The facility census was 39. Findings Include: Review of the medical record for Resident #29 revealed an original admission date on 10/18/21 and a readmission date on 08/14/22. Medical diagnoses included essential primary hypertension, paroxysmal atrial fibrillation, morbid obesity, type II diabetes mellitus without complications, and anxiety disorder. Review of the quarterly Minimum Data Set (MDS) 3.0 assessment dated [DATE] revealed Resident #29 had intact cognition and scored 15 out of 15 on the Brief Interview for Mental Status (BIMS) assessment. [...]

Inspectors wroteBased on observations, staff interview, and facility policy review, the facility failed to ensure pureed food items were prepared at an appropriate texture prior to surveyor intervention for one resident (Resident #17). The deficient practice affected one resident (Resident #17) of one who had a physician ordered pureed diet. The facility census was 39. Findings Include: Observation on 09/04/24 at 10:50 A.M. of pureed food items with [NAME] #120 revealed the cook added one breaded pork chop and ¼ cup of hot water to a blender and started blending. Another ¼ cup of hot water was added to the blender. At 10:57 A.M., [NAME] #120 chopped another breaded pork chop on a cutting board and added it to the blender. Another ½ cup of hot water was added to the blender and continued blending. At 11:00 A.M., [NAME] #120 stopped the blender. [...]

Inspectors wroteBased on observations, staff interviews, review of the facility's policy, review of the Centers for Disease Control and Prevention (CDC) guidance, and record reviews, the facility failed to appropriately wear Personal Protective Equipment (PPE) during the COVID-19 pandemic, and failed to perform appropriate hand hygiene during wound care for Resident #12 and medication administration for Resident #11. This had the potential to affect all 37 residents who resided in the facility.

Inspectors wroteBased on observation, resident and staff interview, review of the facility's policy, and record review, the facility failed to provide appropriate monitoring and treatment of adverse side effects for residents receiving anticoagulation therapy. This affected two (#26 and #234) of three residents reviewed for medications. The facility identified 10 residents on anticoagulation therapy. The facility identified census was 37.

Inspectors wroteBased on observation, staff interview, and record review, the facility failed to provide physician ordered interventions to prevent a resident's decrease in range of motion. This affected one (#4) of one resident reviewed for limited range of motion. The facility identified four residents with contractures. The facility census was 37.

Inspectors wroteBased on staff interview and record review, the facility failed to timely implement dietary recommendations for a resident who had minimal food intake. This affected one (#9) of two residents reviewed for nutrition. The facility identified there were no residents with significant weight loss in the last month. The facility census was 37.

Inspectors wroteBased on observations, staff interviews, and record review, the facility failed to accurately assess a resident's pain. This affected one (#4) of one resident reviewed for pain management. The facility identified 20 residents on a pain management program. The facility census was 37.

Inspectors wroteBased on employee record reviews and staff interviews, the facility failed to provide a continuing education program and twelve hours of training annually for state tested nursing assistants employed by the facility. This had the potential to affect all 37 residents residing in the facility.

Inspectors wroteBased on observations, interviews, review of the facility's policy, and record reviews, the facility failed to maintain a clean, sanitary kitchen equipment and failed to label and date open food items. This had the potential to affect the 37 residents residing in the facility who all received meals from the kitchen.