A list of the most recent deficiencies for Briarwood at Timber Ridge. 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? |
|---|---|---|---|---|
| Include a process for Emergency Preparedness collaboration. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Address subsistence needs for staff and patients. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Establish policies and procedures for medical documentation. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Establish policies and procedures for volunteers. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Provide family notifications of emergency plan. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Establish emergency prep training and testing. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Establish staff and initial training requirements. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Conduct testing and exercise requirements. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Meet other general requirements. | Fire Safety | 2023-07-07 | 2023-08-08 | 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 | 2023-07-07 | 2023-08-08 | N |
| Have stairways and smokeproof enclosures used as exits that meet safety requirements. | Fire Safety | 2023-07-07 | 2023-08-08 | 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 | 2023-07-07 | 2023-08-08 | N |
| Provide properly protected cooking facilities. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Follow proper procedures when the fire alarm was out of service for more than 4 hours. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Follow proper procedures when the automatic sprinkler systems was out of service for more than 10 hours. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Ensure that gas fire places are out of the reach of patients and can be shut off if unit is working improperly. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Have elevators that firefighters can control in the event of a fire. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Have simulated fire drills held at unexpected times. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| To conduct inspection, testing and maintenance of fire doors by qualified individuals. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Ensure receptacles at patient bed locations and where general anesthesia is administered, are tested after initial installation, replacement or servicing. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Ensure that testing and maintenance of electrical equipment is performed. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2023-07-07 | 2023-08-08 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-07-11 | 2023-08-04 | N |
| Ensure services provided by the nursing facility meet professional standards of quality. | Health | 2023-07-11 | 2023-08-04 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2023-07-11 | 2023-08-04 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-07-11 | 2023-08-04 | N |
| Implement a program that monitors antibiotic use. | Health | 2023-07-11 | 2023-08-04 | 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 | 2022-03-25 | 2022-04-18 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-03-25 | 2022-04-18 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2022-03-25 | 2022-04-18 | 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 | 2022-03-25 | 2022-04-18 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2022-03-25 | 2022-04-18 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2022-03-25 | 2022-04-18 | N |
| Provide and implement an infection prevention and control program. | Health | 2022-03-25 | 2022-04-18 | N |
| Give residents notice of Medicaid/Medicare coverage and potential liability for services not covered. | Health | 2019-12-11 | 2020-01-27 | N |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2019-12-11 | 2020-01-27 | N |
| Respond appropriately to all alleged violations. | Health | 2019-12-11 | 2020-01-27 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2019-12-11 | 2020-01-27 | N |
| Notify the resident or the resident?s representative in writing how long the nursing home will hold the resident?s bed in cases of transfer to a hospital or therapeutic leave. | Health | 2019-12-11 | 2020-01-27 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-12-11 | 2020-01-27 | 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 | 2019-12-11 | 2020-01-27 | 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 | 2019-12-11 | 2020-01-27 | 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 | 2019-12-11 | 2020-01-27 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2019-12-11 | 2020-01-27 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2019-12-11 | 2020-01-27 | N |
| Implement a program that monitors antibiotic use. | Health | 2019-12-11 | 2020-01-27 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-12-11 | 2020-01-27 | N |
