A list of the most recent deficiencies for Bria of Forest Edge. 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? |
|---|---|---|---|---|
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-09-12 | 2023-10-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-09-12 | 2023-09-29 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-09-21 | 2023-09-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-21 | 2023-09-22 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2023-09-21 | 2023-09-22 | 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 | 2023-09-21 | 2023-09-22 | Y |
| Use approved construction type or materials. | Fire Safety | 2023-09-12 | 2023-09-22 | 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 | 2023-09-12 | 2023-09-22 | 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 | 2023-09-12 | 2023-09-22 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2023-09-12 | 2023-09-22 | 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 | 2023-09-12 | 2023-09-22 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-09-12 | 2023-09-22 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2023-09-01 | 2023-09-05 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2023-09-01 | 2023-09-04 | Y |
| Respond appropriately to all alleged violations. | Health | 2023-09-01 | 2023-09-04 | Y |
| 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 | 2023-09-01 | 2023-09-04 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2023-09-01 | 2023-09-04 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-09-01 | 2023-09-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-09-01 | 2023-09-04 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2023-09-01 | 2023-09-04 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2023-09-01 | 2023-09-04 | N |
| Provide for the safe, appropriate administration of IV fluids for a resident when needed. | Health | 2023-09-01 | 2023-09-04 | N |
| Provide safe and appropriate respiratory care for a resident when needed. | Health | 2023-09-01 | 2023-09-04 | 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 | 2023-09-01 | 2023-09-04 | N |
| Provide and implement an infection prevention and control program. | Health | 2023-09-01 | 2023-09-04 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-09-01 | 2023-09-04 | N |
| Keep all essential equipment working safely. | Health | 2023-09-01 | 2023-09-04 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-09-01 | 2023-09-04 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-09-01 | 2023-09-01 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-08-18 | 2023-08-19 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2023-08-18 | 2023-08-19 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2023-08-18 | 2023-08-19 | Y |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2023-08-18 | 2023-08-19 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-07-20 | 2023-07-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-07-20 | 2023-07-24 | 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 | 2023-07-20 | 2023-07-24 | Y |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-20 | 2023-07-24 | Y |
| 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 | 2023-04-24 | 2023-05-08 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2023-04-24 | 2023-05-08 | Y |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2023-04-24 | 2023-05-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-01-22 | 2023-01-25 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-12-11 | 2022-12-12 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2022-12-11 | 2022-12-12 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-11-02 | 2022-11-22 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-11-02 | 2022-11-21 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Install a two-hour-resistant firewall separation. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-11-02 | 2022-11-07 | 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 | 2022-11-02 | 2022-11-07 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Ensure that corridors are separated from use areas by walls constructed to limit the passage of smoke. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2022-11-02 | 2022-11-07 | N |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-10-19 | 2022-10-24 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-10-19 | 2022-10-24 | 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 | 2022-10-19 | 2022-10-24 | N |
| Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. | Health | 2022-10-19 | 2022-10-24 | N |
| Assure that each resident?s assessment is updated at least once every 3 months. | Health | 2022-10-19 | 2022-10-24 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-10-19 | 2022-10-24 | N |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-10-19 | 2022-10-24 | N |
| Provide appropriate pressure ulcer care and prevent new ulcers from developing. | Health | 2022-10-19 | 2022-10-24 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-10-19 | 2022-10-24 | 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 | 2022-10-19 | 2022-10-24 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-10-19 | 2022-10-24 | N |
| Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. | Health | 2022-10-19 | 2022-10-24 | N |
| Honor the resident's right to receive visitors of his or her choosing, at the time of his or her choosing. | Health | 2022-09-16 | 2022-09-20 | Y |
| Coordinate assessments with the pre-admission screening and resident review program; and referring for services as needed. | Health | 2022-08-12 | 2022-08-13 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-08-12 | 2022-08-13 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-08-12 | 2022-08-13 | Y |
| Ensure each resident must receive and the facility must provide necessary behavioral health care and services. | Health | 2022-08-12 | 2022-08-13 | Y |
| Provide medically-related social services to help each resident achieve the highest possible quality of life. | Health | 2022-08-12 | 2022-08-13 | Y |
| Provide or get specialized rehabilitative services as required for a resident. | Health | 2022-08-12 | 2022-08-13 | Y |
| Respond appropriately to all alleged violations. | Health | 2022-06-10 | 2022-06-11 | Y |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-06-10 | 2022-06-11 | Y |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-06-10 | 2022-06-11 | Y |
| Ensure that residents are free from significant medication errors. | Health | 2022-06-10 | 2022-06-11 | Y |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2022-01-11 | 2022-02-18 | N |
| Administer the facility in a manner that enables it to use its resources effectively and efficiently. | Health | 2022-01-12 | 2022-01-13 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2022-01-12 | 2022-01-13 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2022-01-12 | 2022-01-13 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-01-12 | 2022-01-13 | N |
| Provide enough food/fluids to maintain a resident's health. | Health | 2022-01-12 | 2022-01-13 | 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 | 2022-01-12 | 2022-01-13 | N |
| Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. | Health | 2022-01-12 | 2022-01-13 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-01-12 | 2022-01-13 | 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 | 2022-01-12 | 2022-01-13 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-01-12 | 2022-01-13 | N |
| Designate a qualified infection preventionist to be responsible for the infection prevent and control program in the nursing home. | Health | 2022-01-12 | 2022-01-13 | N |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2022-01-12 | 2022-01-13 | N |
| Put firmly secured handrails on each side of hallways. | Health | 2022-01-12 | 2022-01-13 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2022-01-11 | 2022-01-13 | 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 | 2022-01-11 | 2022-01-13 | 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 | 2022-01-11 | 2022-01-13 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Have exits that are accessible at all times. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Have properly located and lighted "Exit" signs. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Have an enclosure around a vertical opening shaft. | Fire Safety | 2022-01-11 | 2022-01-13 | 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 | 2022-01-11 | 2022-01-13 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Install an approved automatic sprinkler system. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Provide a written emergency evacuation plan. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Have posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Have restrictions on the use of flammable curtains. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Have restrictions on the use of portable space heaters. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2022-01-11 | 2022-01-13 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2022-01-11 | 2022-01-13 | 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 | 2021-12-23 | 2021-12-24 | Y |
| Post nurse staffing information every day. | Health | 2021-12-23 | 2021-12-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-10-26 | 2021-10-26 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-10-26 | 2021-10-26 | Y |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2021-10-26 | 2021-10-26 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-10-26 | 2021-10-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-10-26 | 2021-10-26 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-10-26 | 2021-10-26 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2021-08-19 | 2021-09-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-08-19 | 2021-09-13 | Y |
