A list of the most recent deficiencies for Briarfield at Ashley Circle. 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? |
|---|---|---|---|---|
| Establish a governing body that is legally responsible for establishing and implementing policies for managing and operating the facility and appoints a properly licensed administrator responsible for managing the facility. | Health | 2023-12-09 | 2023-12-09 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2023-07-21 | 2023-08-01 | Y |
| 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 | 2023-03-02 | 2023-03-28 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-03-02 | 2023-03-28 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-03-02 | 2023-03-28 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-03-02 | 2023-03-28 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-03-02 | 2023-03-28 | N |
| Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason. | Health | 2022-11-28 | 2022-11-28 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-01-27 | 2022-02-08 | Y |
| Provide and implement an infection prevention and control program. | Health | 2022-01-27 | 2022-02-08 | Y |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2021-03-22 | 2021-04-22 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2021-03-22 | 2021-04-22 | 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 | 2020-02-06 | 2020-03-19 | 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 | 2020-02-06 | 2020-03-19 | N |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2020-02-06 | 2020-03-19 | 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 | 2020-02-05 | 2020-03-19 | N |
| Install emergency lighting that can last at least 1 1/2 hours. | Fire Safety | 2020-02-05 | 2020-03-19 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2020-02-05 | 2020-03-19 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2020-02-05 | 2020-03-19 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2020-02-05 | 2020-03-19 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2020-02-05 | 2020-03-19 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2020-02-06 | 2020-02-14 | 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 | 2019-01-16 | 2019-02-08 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2019-01-16 | 2019-02-08 | 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 | 2019-01-16 | 2019-02-08 | N |
| Ensure each resident?s drug regimen must be free from unnecessary drugs. | Health | 2019-01-16 | 2019-02-08 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-01-16 | 2019-02-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2019-01-14 | 2019-02-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2019-01-14 | 2019-02-08 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2019-01-14 | 2019-02-08 | N |
