Heritage Hall - Brookneal

In the surveyor’s words

From the most serious findings on record at Heritage Hall - Brookneal, in the surveyor’s own words.

• No harm, potential for more than minimal, patternF578Dec 16, 2021

  Based on record review, interview and review of facility policy, the facility failed to ensure residents had the right to formulate an advance directive and/or prominently displayed information in the medical record about whether or not the resident executed an advance directive. This affected five (Residents (R)4, R12, R18, R33 and R43) of five residents reviewed for advance directives. Additionally, R4 did not receive written information regarding advance directives in accordance with facility policy. Findings include: Review of the facility's policy titled Advance Directives © 2001 MED-PASS, Inc. […]

• No harm, potential for more than minimal, isolatedF582Dec 16, 2021

  Based on record review and interview, the facility failed to provide a Form CMS- (Centers for Medicaid and Medicare Services) Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) and Form CMS- (Centers for Medicaid and Medicare Services) Notice of Medicare Non-Coverage (NOMNC) to two of three residents (Resident (R) 207 and R29) reviewed for beneficiary notices. This failure prevented R29 and R207 or their responsible party from making an immediate appeal of the decision to end Medicare coverage of services. Findings include: Review of the medical records revealed that R207 and R29 were given the incorrect forms when they were discharged from a Medicare covered Part A stay. These two residents were discharged back into the facility under skilled nursing. […]

• No harm, potential for more than minimal, isolatedF641Dec 16, 2021

  Based on record review, staff interview, and review of the Resident Assessment Instrument (RAI) Manual, the facility failed to ensure one resident (Resident (R) 15) out of 26 sampled residents had an accurate Minimum Data Set (MDS) assessment. Findings include: Review of the RAI Manual, dated 10/01/19, indicated, . Active diagnoses [MEDICAL RECORD OR PHYSICIAN ORDER] .It is important to note here that information obtained should cover the same observation period as specified by the MDS items on the assessment and should be validated for accuracy (what the resident's actual status was during that observation period) by the IDT completing the assessment. […]

• No harm, potential for more than minimal, isolatedF657Dec 16, 2021

  Based on observation, record review, interviews, and review of facility policy, the facility failed to ensure a resident's Care Plan was revised for one of 25 residents (Resident (R) 15) sampled which accurately reflected the resident's history of Post-Traumatic Stress Disorder ([CONDITION(S)]). The facility also failed to ensure R29's representative was invited to care plan meetings. Findings include: 1. Review of R15's electronic medical record (EMR) undated Face Sheet, located under the tab titled Face Sheet indicated R15 was admitted to the facility on [DATE], with a diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . […]

• No harm, potential for more than minimal, isolatedF755Dec 16, 2021

  Based on record review and interviews, the facility failed to assure one resident (R)22 of one reviewed for timely medication administration received ordered pain medication in a timely manner. The facility failed to reorder R22's pain medication in a timely manner. Findings include: Review of R22's electronic medical record (EMR) undated Face Sheet, located under the tab titled Face Sheet indicated R22 was admitted to the facility on [DATE], with diagnoses including [CONDITION(S)] following cerebral infarction (stroke) and [CONDITION(S)]. Review of R22's annual Minimum Data Set (MDS) with an Assessment Reference Date (ARD) 10/28/21 indicated a Brief Interview for Mental Status (BIMS) score of 15 out of 15 which indicated R22 had intact cognition. […]