Brian Center of Alleghany

In the surveyor’s words

From the most serious findings on record at Brian Center of Alleghany, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF657Jan 24, 2024

  Based on resident interview, staff interview, facility document review and clinical record review, the facility staff failed to review and revise the comprehensive care plan for two of twenty-three residents in the survey sample (Residents #57 and #61). The findings include: 1. Resident #57 did not have a comprehensive care plan review/meeting conducted by the interdisciplinary team, including the resident and/or family member, after each minimum data set (MDS) for over a year. Resident #57 (R57) was admitted to the facility with diagnoses that included COPD (chronic obstructive pulmonary disease), emphysema, gastroesophageal reflux disease, chronic respiratory failure, osteoarthritis, peripheral vascular disease, osteoporosis, depression and protein-calorie malnutrition. […]

• No harm, potential for more than minimal, patternF880Jan 24, 2024

  Based on observation, staff interview, clinical record review and facility documentation review, the facility staff failed to implement infection control practices to prevent the transmission of communicable diseases and infections on 2 of 5 units, which had the potential of affect multiple residents. The findings included: 1. For Resident #18, who was on transmission-based precautions, the facility staff failed to wear proper PPE (personal protective equipment) while providing care, to prevent the transmission of infection(s) within the facility. On 1/22/24 at 11 am, resident #18 was observed from the hallway. It was noted that on the room door frame there was a sign that indicated Stop: Contact precautions. […]

• No harm, potential for more than minimal, isolatedF578Jan 24, 2024

  Based on staff interview, clinical record review, and state code, the facility staff failed to document a valid do not resuscitate order form for one of twenty-three residents in the survey sample (Resident 59). The findings include: Resident #59's durable do not resuscitate order form (DDNR), a portable, state-issued form communicating the resident's DNR status when transported outside of the nursing facility, was incomplete and included no required signatures of the physician or the resident's authorized representative. Resident #59 (R59) was admitted to the facility with diagnoses that included diabetes, neuropathy, dysphagia, cerebral infarction with hemiparesis, dementia, psychotic disturbance, mood disturbance, anxiety, chronic kidney disease and insomnia. […]

• No harm, potential for more than minimal, isolatedF655Jan 24, 2024

  Based on staff interview, clinical record review, and facility documentation review, the facility staff failed to develop and implement a baseline care plan for one Resident (Resident #234) in a survey sample of 23 Residents, which should to direct the patient centered care of the resident. The findings included: On 1/23/24, a clinical record review was conducted of Resident #234's chart. This revealed that Resident #234 was admitted to the facility on [DATE], but the baseline care plan was not developed until 1/22/24. On 1/23/24, the unit manager/LPN #4, was asked about the baseline care plan for Resident #234. LPN #4 provided the surveyor with a 3-ring binder that was kept at the nursing station that contained baseline care plans. […]

• No harm, potential for more than minimal, isolatedF656Jan 24, 2024

  Based on staff interview, clinical record review, and facility document review the facility failed to develop a care plan for one of 23 residents. Resident #1 (R1) had an admitting diagnosis of PTSD (Post Traumatic Stress Disorder), and a care plan was not developed. The Findings Include: Diagnoses for R1 included: PTSD, anxiety, depression, and obsessive-compulsive disorder. The most current MDS (minimum data set) was a quarterly assessment with an ARD (assessment reference date) of 12/17/23. R1 was assessed with a cognitive score of 12 indicating cognitively intact. A review of the Trauma Informed Screen assessment dated [DATE] revealed R1 was in Vietnam and did not reveal any other information related to PTSD. […]