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Deficiency Records for Briarcliff Health and Rehabilitation Center
A list of the most recent deficiencies for Briarcliff Health and Rehabilitation 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 Briarcliff Health and Rehabilitation 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? |
|---|---|---|---|---|
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2024-09-06 | 2024-09-27 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2024-09-06 | 2024-09-27 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2024-09-06 | 2024-09-27 | N |
| Implement emergency and standby power systems. | Fire Safety | 2024-09-06 | 2024-09-12 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2024-09-06 | 2024-09-12 | 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 | 2024-09-06 | 2024-09-06 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2024-08-12 | 2024-09-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2024-08-12 | 2024-09-04 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2024-08-12 | 2024-09-04 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2024-08-12 | 2024-09-04 | 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 | 2024-08-12 | 2024-09-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2024-08-12 | 2024-09-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2024-08-12 | 2024-09-04 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2024-08-12 | 2024-09-04 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-11-29 | 2023-12-28 | Y |
| Honor the resident's right to and the facility must promote and facilitate resident self-determination through support of resident choice. | Health | 2023-09-01 | 2023-09-29 | Y |
| Implement emergency and standby power systems. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-31 | 2023-08-31 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-07-14 | 2023-08-19 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-07-14 | 2023-08-19 | N |
| Assist a resident in gaining access to vision and hearing services. | Health | 2023-07-14 | 2023-08-19 | N |
| 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 | 2023-07-14 | 2023-08-19 | 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 | 2023-07-14 | 2023-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-14 | 2023-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-20 | 2022-12-02 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-10-20 | 2022-12-02 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2022-08-17 | 2022-09-03 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-05-10 | 2022-06-23 | N |
| Develop and maintain an Emergency Preparedness Program (EP). | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Conduct risk assessment and an All-Hazards approach. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Develop Emergency Preparedness policies and procedures. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Establish procedures for tracking staff and patients during an emergency. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Establish policies and procedures including evacuation. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Develop a communication plan. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| List the names and contact information of those in the facility. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Provide emergency officials' contact information. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Establish methods for sharing information. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Establish emergency prep training and testing. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Establish staff and initial training requirements. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Implement emergency and standby power systems. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Install a fire alarm system that can be heard throughout the facility. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Have proper fire barriers, ventilation and signs for the transfilling of oxygen. | Fire Safety | 2022-05-10 | 2022-06-17 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-04-04 | 2022-06-16 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-04-04 | 2022-06-16 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-04-04 | 2022-06-16 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-04-04 | 2022-06-16 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-04-04 | 2022-06-16 | N |
| Assure the security of all personal funds of residents deposited with the facility. | Health | 2022-04-04 | 2022-05-01 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-04-04 | 2022-05-01 | N |
| 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 | 2022-04-04 | 2022-05-01 | N |
| Assess the resident when there is a significant change in condition | Health | 2022-04-04 | 2022-05-01 | N |
| Encode each resident?s assessment data and transmit these data to the State within 7 days of assessment. | Health | 2022-04-04 | 2022-05-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-04-04 | 2022-05-01 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-04-04 | 2022-05-01 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-04-04 | 2022-05-01 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-04-04 | 2022-05-01 | N |
| Provide appropriate care for residents who are continent or incontinent of bowel/bladder, appropriate catheter care, and appropriate care to prevent urinary tract infections. | Health | 2022-04-04 | 2022-05-01 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-04-04 | 2022-05-01 | N |
| 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 | 2022-04-04 | 2022-05-01 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2022-04-04 | 2022-05-01 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2022-04-04 | 2022-05-01 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2022-04-04 | 2022-05-01 | 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 | 2022-04-04 | 2022-05-01 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2022-04-04 | 2022-05-01 | Y |
| 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 | 2022-04-04 | 2022-05-01 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-12-29 | 2022-01-20 | N |
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