Briar Creek Health Center

In the surveyor’s words

From the most serious findings on record at Briar Creek Health Center, in the surveyor’s own words.

• Actual harm, isolatedF697Mar 7, 2024

  Based on record review, resident interview, and staff interviews the facility failed to assess a resident's pain and administer pain medication ordered by the physician for 1 of 2 residents (Resident #70) when the resident complained of left ankle pain. Resident #70 experienced pain of 8 on a scale of 0-10 (10 being the worst pain) from 1:00 am on 1/12/2024 until her medication arrived twelve hours after she was readmitted to the facility from the hospital for a fractured left fibula. Findings included: Resident #70 was admitted to the facility on [DATE] and she was readmitted from the hospital on 2/26/2024 with diagnoses of left fibula fracture with surgical repair and osteoarthritis. […]

• Actual harm, isolatedF755Mar 7, 2024

  Based on record review, resident interview, and staff interviews the facility failed to obtain pain medication ordered by the physician for 1 of 2 residents (Resident #70) when the resident was admitted to the facility after surgical repair of a left fibula fracture. Resident #70 experienced pain of 8 on a scale of 0-10 (1- being the worst pain) from 1:00 am on 1/12/2024 until her medication was administered on 1/12/2024 at 1:06 pm on 1/12/2024. Findings included: Resident #70 was admitted to the facility on [DATE] and she was readmitted from the hospital on 2//2024 with diagnoses of left fibula fracture with surgical repair and osteoarthritis. […]

• No harm, potential for more than minimal, widespreadF851May 6, 2025

  Based on record review and staff interviews the facility failed to electronically submit direct care staffing information based on payroll data to the Centers for Medicare and Medicaid Services (CMS) as required for quarter 3 (April 1 through June 30, 2024), quarter 4 (July 1 through September 30, 2024) of federal fiscal year (FY) 2024 and quarter 1 of FY 2025 (October 1 through December 31, 2024). This failure occurred for 3 of 3 quarters reviewed. The findings included: Review of the Payroll Based Journal (PBJ) staffing data reports from the Certification and Survey Provider Enhanced Reports (CASPER) database revealed the facility failed to submit the required PBJ staffing data for the third and fourth quarters of federal FY 2024 and the first quarter of federal FY 2025. […]

• No harm, potential for more than minimal, patternF812Mar 7, 2024

  Based on observations and staff interviews, the facility failed to label and cover cooked food, discard expired food in the walk-in refrigerator, and ensure resident meal trays, baking sheets, and pans were not stacked wet for 1 of 2 kitchen observations. These practices had the potential to affect food served to residents. The findings included: The facility kitchen was toured on [DATE] at 7:47 AM. An observation was conducted of the walk-in refrigerator and the following were observed: a. A free-standing rack was labeled cooling rack had 2 deep steamer pans on the top shelf of the rack. There was cooked white colored meat in the pans that were floating in pink colored liquid. The sheet on the cooling rack noted turkey [DATE] 12:42 PM. […]

• No harm, potential for more than minimal, isolatedF655May 6, 2025

  Based on record reviews and staff interviews, the facility failed to develop a baseline care plan with goals that addressed a resident's pain and opioid pain medication for 1 of 1 resident reviewed for baseline care plan (Resident #156). Findings Included: Resident #156 was admitted to the facility on [DATE] with a diagnosis that included multiple fractures post fall. A review of Resident #156's Physician order summary dated 5/1/2025 included: - Oxycodone 5mg every 6 hours as needed for pain. - Acetaminophen oral tablet 500 mg, 2 tablets by mouth three times a day for manage of pain for 10 days. - Assess pain every shift using numeric 1 to 10 scale. Document findings and interventions in nursing notes. […]