Harmony at Brookberry Farm

The facility failed to provide table service with a napkin and non-disposable place settings, including knives, forks, spoons, plates, and beverage containers, for residents receiving meals in their rooms. Observations and interviews revealed that meals were being served in styrofoam trays and cups with disposable plastic utensils. Staff and administration admitted to using disposable items for room service, incorrectly believing the regulation did not apply to delivered meals.

The facility failed to provide table service with a napkin and non-disposable place settings for residents receiving meals in their rooms. Observations and interviews revealed that meals were being served on styrofoam trays with disposable plastic utensils and styrofoam cups instead of the required non-disposable items.

The facility failed to ensure proper referral and follow-up to meet the healthcare needs of residents. Specifically, for two sampled residents, the facility failed to provide necessary physician orders in response to abnormal laboratory results for blood thinning medication and missed a laboratory order.

The facility failed to ensure proper referral and follow-up to meet the healthcare needs of residents. Specifically, the facility failed to monitor medication for a resident on a blood thinner and failed to follow up on a missed laboratory order for two sampled residents.

The facility failed to ensure that resident assessments were completed within 30 days of admission and at least annually thereafter. These assessments must include functional, psychosocial, and cognitive status to determine the resident's level of functioning and need for referrals.

The facility failed to ensure that annual resident assessments were completed for 2 of 5 sampled residents. Specifically, for resident #2, no care plans were available for review following the care plan dated 11/10/22.

The facility failed to ensure that one of five sampled residents had a current FL2 medical examination on file. Records showed no available FL2 for Resident #5, despite the resident being admitted in June 2022.

The facility failed to provide adequate personal care assistance to four of five sampled residents. Specific instances included a resident who soiled herself while waiting for help, a resident with a decubitus ulcer who soiled himself, a resident who removed her oxygen due to shortness of breath, and a resident who remained on the floor for one hour following a fall.

The facility failed to ensure one of five sampled residents had a current FL-2 medical examination on file. A review of the resident's record showed no available FL-2, despite the resident being admitted in June 2022.

The facility failed to provide adequate personal care and supervision for four of five sampled residents. Specific instances included a resident who soiled herself while waiting for assistance, a resident with a decubitus ulcer who was left soiled, a resident who removed her oxygen, and a resident who remained on the floor for one hour after activating a call bell.

The facility failed to ensure timely response to call bells, with 156 instances in December 2023 where response times exceeded 40 minutes. Family members and residents reported difficulty finding staff to assist with care, particularly during shift changes and weekends.