Bria of Forest Edge

In the surveyor’s words

From the most serious findings on record at Bria of Forest Edge, in the surveyor’s own words.

• Immediate jeopardy, widespreadF584Feb 5, 2024

  Based on observation, records review and interviews the facility failed to provide a safe and home like environment by not maintaining comfortable and safe temperature levels in the entire premises of the facility. This failure affected all 258 residents residing in the facility, who were all subjected to hazardous temperatures and one resident (R8) who was sent to the hospital and admitted due to hypothermia. This was identified as an Immediate Jeopardy which began on 1/16/24 at 10:30 am per (1/16/24) facility temperature log which documents a residents' rooms temperature range of 53F (Fahrenheit) to 63F. On 1/19/24 at 09:16 am V1 (Administrator) was notified of the immediate jeopardy. The facility presented a final removal plan on 1/22/24 at 4:49 am which was not approved. […]

• Immediate jeopardy, isolatedF600Jul 20, 2023

  There are two Deficiency Practice Statements: 1) Based on interview and record review the facility failed to protect a resident from being physically abused. This affects two of six sampled residents (R6 and R10) reviewed. As a result of this failure, R10 attacked R6, a cognitive impaired resident. R6 sustained multiple injuries (black eyes, bruising, facial soft tissue swelling, and distorted nasal bones). This failure resulted in Immediate Jeopardy which began 5/25/2023 when R6 was attacked by R10 with no immediate intervention from staff. V1 (administrator) was informed of the immediate jeopardy and a template was presented on 6/29/2023. On 7/11/2023 an acceptable removal plan was received. […]

• Immediate jeopardy, isolatedF689Jul 20, 2023

  Based on interview and record review the facility failed to provide adequate supervision to monitor residents with aggressive behavior and those residents at risk for being abused. This affects two of six sampled residents (R6 and R10) reviewed for supervision. As a result of this failure, R10 attacked R6, a cognitive impaired resident. R6 sustained multiple injuries (black eyes, bruising, facial soft tissue swelling, and distorted nasal bones). This failure resulted in Immediate Jeopardy which began 5/25/2023 when R6 was attacked by R10 with no immediate intervention from staff. V1 (administrator) was informed of the immediate jeopardy and a template was presented on 6/29/2023. On 7/11/2023 an acceptable removal plan was received. […]

• Immediate jeopardy, isolatedF689Oct 26, 2021

  Based on observations, interviews and review of records the facility failed to provide safety intervention and supervision for 2 of 2 residents (R1 and R2) reviewed for accidents and supervision. R1 sustained multiple 2nd degree [CONDITION(S)] to right hand, fingers, chest and thigh. R2 expired as a result of being discovered submerged under water in a tub at the shower room for approximately 3 to 4 hours. These failures resulted in an Immediate Jeopardy on [DATE] with the potential to affect the safety of 144 residents that requires supervision / assistance per facility form CMS 672. […]

• Actual harm, isolatedF689Oct 3, 2024

  Based on interview and record review, the facility failed to provide adequate supervision to a resident (R194) who is high risk for falls. This failure resulted in R194 sustaining a fall which required R194 to go to the local hospital due to sustaining a laceration above R194's left eyebrow, an acute interior column fracture of the C6 vertebrae without significant displacement and R194 to wear a neck brace for 8 weeks. Findings include: The facility's Initial Report to local State Agency dated 08/26/24 at 8:12 am, documents, in part R1 sustained a fall with a cut to the upper left eyebrow requiring staples. The facility's Final Report to local State Agency dated 09/02/24 at 6:46 pm, documents, in part R194 was transferred to the local hospital. […]