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Deficiency Records for Briarcrest Nursing Center
A list of the most recent deficiencies for Briarcrest Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
A list of the most recent deficiencies for Briarcrest Nursing Center. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2024-08-13 | 2024-09-12 | Y |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-08-13 | 2024-09-12 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2024-08-20 | 2024-09-06 | Y |
| Honor each resident's preferences, choices, values and beliefs. | Health | 2024-07-11 | 2024-07-30 | Y |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-07-11 | 2024-07-30 | Y |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2024-07-11 | 2024-07-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2024-06-25 | 2024-07-24 | Y |
| Provide activities to meet all resident's needs. | Health | 2024-06-25 | 2024-07-24 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-06-25 | 2024-07-24 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2024-06-25 | 2024-07-24 | Y |
| Conduct testing and exercise requirements. | Fire Safety | 2024-03-12 | 2024-04-09 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2024-03-12 | 2024-04-09 | N |
| Construct fire resistant interior walls. | Fire Safety | 2024-03-12 | 2024-04-09 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2024-03-12 | 2024-04-09 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2024-03-12 | 2024-04-09 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-03-12 | 2024-04-09 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2024-03-12 | 2024-04-09 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-03-12 | 2024-04-09 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2024-03-12 | 2024-04-09 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2024-03-07 | 2024-04-05 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2024-03-07 | 2024-04-05 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2024-03-07 | 2024-04-05 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2024-03-07 | 2024-04-05 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2024-03-07 | 2024-04-05 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2024-03-07 | 2024-04-05 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2024-03-07 | 2024-04-05 | N |
| Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason. | Health | 2024-03-07 | 2024-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-03-07 | 2024-04-05 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2024-03-07 | 2024-04-05 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2024-03-07 | 2024-04-05 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-03-07 | 2024-04-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2024-03-07 | 2024-04-05 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2024-03-07 | 2024-04-05 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-03-07 | 2024-04-05 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-03-07 | 2024-04-05 | N |
| Keep all essential equipment working safely. | Health | 2024-03-07 | 2024-04-05 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-01-24 | 2024-02-23 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2024-01-24 | 2024-02-23 | Y |
| Provide and implement an infection prevention and control program. | Health | 2024-01-08 | 2024-02-08 | Y |
| Provide appropriate foot care. | Health | 2023-11-09 | 2023-12-08 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-10-17 | 2023-11-08 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-10-17 | 2023-11-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-07-21 | 2023-08-21 | Y |
| Ensure that feeding tubes are not used unless there is a medical reason and the resident agrees; and provide appropriate care for a resident with a feeding tube. | Health | 2023-05-15 | 2023-06-14 | Y |
| Provide and implement an infection prevention and control program. | Health | 2023-05-15 | 2023-06-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-04-20 | 2023-05-04 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-04-07 | 2023-05-04 | Y |
| Give the resident's representative the ability to exercise the resident's rights. | Health | 2023-04-05 | 2023-04-18 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-03-28 | 2023-04-18 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-03-28 | 2023-04-18 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-21 | 2023-03-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-02-21 | 2023-03-21 | Y |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-21 | 2023-03-21 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-02-09 | 2023-03-09 | Y |
| Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. | Health | 2023-02-01 | 2023-03-01 | Y |
| Keep all essential equipment working safely. | Health | 2023-01-11 | 2023-02-16 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-12-21 | 2023-01-25 | Y |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2022-12-21 | 2023-01-25 | Y |
| Report COVID19 data to residents and families. | Health | 2022-12-21 | 2023-01-25 | Y |
| Ensure staff are vaccinated for COVID-19 | Health | 2022-12-21 | 2023-01-25 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2022-11-22 | 2022-12-01 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-10-09 | 2022-11-21 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-10-09 | 2022-11-21 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-09-30 | 2022-10-14 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-30 | 2022-10-14 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-09-30 | 2022-10-14 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-09-19 | 2022-10-05 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-08-30 | 2022-09-08 | Y |
| Give their staff education on dementia care, and what abuse, neglect, and exploitation are; and how to report abuse, neglect, and exploitation. | Health | 2022-07-27 | 2022-08-19 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-06-29 | 2022-08-12 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-07-07 | 2022-08-01 | Y |
| Ensure nurse aides have the skills they need to care for residents, and give nurse aides education in dementia care and abuse prevention. | Health | 2022-07-07 | 2022-08-01 | Y |
| Ensure that residents are fully informed and understand their health status, care and treatments. | Health | 2022-07-08 | 2022-07-28 | Y |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2022-07-08 | 2022-07-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-07-08 | 2022-07-28 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2022-07-08 | 2022-07-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-05-26 | 2022-07-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-04-06 | 2022-06-21 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-06 | 2022-06-21 | Y |
| Post nurse staffing information every day. | Health | 2022-04-06 | 2022-06-21 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-13 | 2022-05-04 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-04-12 | 2022-05-04 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2021-12-22 | 2022-02-07 | N |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2021-12-22 | 2022-02-07 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-12-22 | 2022-02-07 | N |
| Ensure residents have reasonable access to and privacy in their use of communication methods. | Health | 2021-12-22 | 2022-02-07 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2021-12-22 | 2022-02-07 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2021-12-22 | 2022-02-07 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-12-22 | 2022-02-07 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-22 | 2022-02-07 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2021-12-22 | 2022-02-07 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2021-12-22 | 2022-02-07 | N |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-12-22 | 2022-02-07 | N |
| Post nurse staffing information every day. | Health | 2021-12-22 | 2022-02-07 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-12-22 | 2022-02-07 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2021-12-22 | 2022-02-07 | N |
| Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options. | Health | 2021-12-22 | 2022-02-07 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-12-22 | 2022-02-07 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2021-12-22 | 2022-02-07 | N |
| Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action. | Health | 2021-12-22 | 2022-02-07 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-12-22 | 2022-02-07 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2021-12-22 | 2022-02-07 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2021-12-22 | 2022-02-07 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-12-22 | 2022-02-07 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2021-12-22 | 2022-01-21 | Y |
| Provide emergency officials' contact information. | Fire Safety | 2021-12-16 | 2022-01-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2021-12-16 | 2022-01-04 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-12-16 | 2022-01-04 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-12-16 | 2022-01-04 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-12-16 | 2022-01-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-06 | 2021-12-20 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-11-10 | 2021-11-23 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-11-10 | 2021-11-23 | Y |
| Ensure each resident receives an accurate assessment. | Health | 2019-11-14 | 2019-12-30 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2019-11-14 | 2019-12-30 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2019-11-14 | 2019-12-30 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-11-14 | 2019-12-30 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-11-14 | 2019-12-30 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2019-11-14 | 2019-12-30 | N |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2019-11-14 | 2019-12-30 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2019-11-14 | 2019-12-30 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2019-11-14 | 2019-12-30 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2019-11-14 | 2019-12-30 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2019-11-14 | 2019-12-30 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2019-11-14 | 2019-12-30 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2019-11-14 | 2019-12-30 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2019-11-14 | 2019-12-30 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-11-14 | 2019-12-30 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Provide exit doors that are held open by devices that will automatically close on the activation of a fire alarm or smoke detector. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Have properly installed hallway dispensers for alcohol-based hand rub. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-11-12 | 2019-12-18 | N |
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