A list of the most recent deficiencies for Briar Place Nursing. 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? |
|---|---|---|---|---|
| Honor the resident's right to share a room with spouse or roommate of choice and receive written notice before a change is made. | Health | 2024-02-10 | 2024-02-23 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2024-02-10 | 2024-02-23 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2024-01-22 | 2024-02-02 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-10-08 | 2023-10-20 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-10-08 | 2023-10-20 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-10-08 | 2023-10-20 | N |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2023-10-08 | 2023-10-20 | N |
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, or who has a history of trauma and/or post-traumatic stress disorder. | Health | 2023-10-08 | 2023-10-20 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-10-08 | 2023-10-20 | 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 | 2023-10-08 | 2023-10-20 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-10-08 | 2023-10-20 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2023-10-08 | 2023-10-20 | Y |
| 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 | 2023-10-04 | 2023-10-20 | 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 | 2023-10-04 | 2023-10-20 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-10-04 | 2023-10-20 | 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 | 2023-10-04 | 2023-10-20 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Properly install and monitor supervisory attachments on automatic sprinkler systems. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-10-04 | 2023-10-20 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-10 | 2023-08-15 | Y |
| Honor the resident's right to be treated with respect and dignity and to retain and use personal possessions. | Health | 2023-06-09 | 2023-06-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-06-09 | 2023-06-26 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2023-05-19 | 2023-05-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-05-19 | 2023-05-24 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2023-02-15 | 2023-02-16 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-02-15 | 2023-02-16 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-15 | 2023-02-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-01-06 | 2023-01-20 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-01-06 | 2023-01-20 | Y |
| Install smoke barrier doors that can resist smoke for at least 20 minutes. | Fire Safety | 2022-10-11 | 2022-11-02 | 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 | 2022-10-11 | 2022-11-01 | 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 | 2022-10-11 | 2022-11-01 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Ensure that any exit in an area undergoing construction, repair, or improvements shall be inspected daily to ensure its ability to be used instantly in case of emergency. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-10-11 | 2022-11-01 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-09-29 | 2022-10-15 | 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 | 2022-09-29 | 2022-10-15 | 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 | 2022-09-29 | 2022-10-15 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-09-29 | 2022-10-15 | 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 | 2022-09-29 | 2022-10-15 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-09-29 | 2022-10-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-09-29 | 2022-10-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-29 | 2022-10-15 | 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 | 2022-09-29 | 2022-10-15 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-09-29 | 2022-10-15 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-06-09 | 2022-06-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-06-09 | 2022-06-24 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-05-19 | 2022-05-27 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-05-19 | 2022-05-27 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-03-29 | 2022-04-20 | Y |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-20 | 2022-01-21 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-12-21 | 2022-01-12 | Y |
| Not transfer or discharge a resident without an adequate reason; and must provide documentation and convey specific information when a resident is transferred or discharged. | Health | 2021-12-21 | 2022-01-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-21 | 2022-01-12 | Y |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2021-12-21 | 2022-01-12 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-27 | 2022-01-12 | Y |
| Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. | Health | 2021-10-27 | 2021-11-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2021-10-27 | 2021-11-08 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-09-10 | 2021-09-23 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-09-10 | 2021-09-23 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2021-09-10 | 2021-09-23 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-09-10 | 2021-09-23 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-09-10 | 2021-09-23 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2021-08-05 | 2021-08-19 | 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 | 2021-08-05 | 2021-08-19 | 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 | 2021-08-05 | 2021-08-19 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2021-08-05 | 2021-08-19 | 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 | 2021-08-05 | 2021-08-19 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2021-08-05 | 2021-08-19 | N |
| Provide and implement an infection prevention and control program. | Health | 2021-08-05 | 2021-08-19 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-05 | 2021-08-19 | Y |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2021-08-05 | 2021-08-19 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-08-05 | 2021-08-19 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-08-05 | 2021-08-19 | Y |
| Establish staff and initial training requirements. | Fire Safety | 2021-08-11 | 2021-08-19 | 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 | 2021-08-11 | 2021-08-19 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2021-08-11 | 2021-08-19 | 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 | 2021-08-11 | 2021-08-19 | N |
| Construct fire resistant interior walls. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Have properly installed electrical wiring and gas equipment. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Install properly constructed and protected linen or trash chutes. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Provide properly sized and located linen or trash receptacles. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Have proper power supply for life support equipment. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2021-08-11 | 2021-08-19 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2021-06-15 | 2021-06-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-06-15 | 2021-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-06-15 | 2021-06-16 | Y |
| Provide appropriate colostomy, urostomy, or ileostomy care/services for a resident who requires such services. | Health | 2021-06-15 | 2021-06-16 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2021-06-15 | 2021-06-16 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-04-16 | 2021-06-16 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-04-16 | 2021-06-16 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-16 | 2021-04-29 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2021-04-16 | 2021-04-29 | Y |
