Deficiency Records for Briarcliff Nursing and Rehabilitation Center
Updated as of March 01, 2019
This is not the most recent data for Briarcliff Nursing and Rehabilitation Center. For the most recent information, click here.
A list of the most recent deficiencies for Briarcliff Nursing 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 generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2018-09-26 | 2018-10-11 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2018-10-01 | 2018-10-09 | N |
| Honor the resident's right to voice grievances without discrimination or reprisal and the facility must establish a grievance policy and make prompt efforts to resolve grievances. | Health | 2018-10-01 | 2018-10-05 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2018-10-01 | 2018-10-05 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2018-10-01 | 2018-10-05 | 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 | 2018-10-01 | 2018-10-04 | 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 | 2018-10-01 | 2018-10-04 | 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 | 2018-10-01 | 2018-10-03 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2018-10-01 | 2018-10-03 | N |
| Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature. | Health | 2018-10-01 | 2018-10-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2018-10-01 | 2018-10-03 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-10-01 | 2018-10-03 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2018-09-26 | 2018-10-02 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2018-10-01 | 2018-10-02 | N |
| Keep residents' personal and medical records private and confidential. | Health | 2018-10-01 | 2018-10-02 | 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 | 2018-10-01 | 2018-10-02 | N |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-10-01 | 2018-10-02 | N |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2018-08-23 | 2018-08-24 | 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 ne | Health | 2018-08-23 | 2018-08-24 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2018-08-23 | 2018-08-24 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2018-03-02 | 2018-05-24 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2018-04-23 | 2018-05-17 | Y |
| Respond appropriately to all alleged violations. | Health | 2018-04-23 | 2018-05-17 | Y |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-10-05 | 2017-10-26 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-10-05 | 2017-10-26 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-10-05 | 2017-10-26 | Y |
| Ensure smoke barriers are constructed to a 1 hour fire resistance rating. | Fire Safety | 2017-08-23 | 2017-09-22 | N |
| Meet other general requirements that are deficient. | Fire Safety | 2017-08-23 | 2017-09-22 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2017-08-23 | 2017-09-22 | 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 | 2017-08-23 | 2017-09-15 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2017-08-23 | 2017-09-15 | N |
| Ensure electrical receptacles or cover plates have distinctive color or marking. | Fire Safety | 2017-08-23 | 2017-09-15 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-08-24 | 2017-08-28 | N |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2017-08-24 | 2017-08-28 | N |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2017-08-24 | 2017-08-28 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2017-08-24 | 2017-08-28 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2017-08-24 | 2017-08-26 | N |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2017-08-24 | 2017-08-26 | N |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2017-08-24 | 2017-08-26 | N |
| Tell 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 | 2017-08-24 | 2017-08-25 | N |
| Provide housekeeping and maintenance services. | Health | 2017-08-24 | 2017-08-25 | N |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2017-08-24 | 2017-08-25 | N |
| Store, cook, and serve food in a safe and clean way. | Health | 2017-08-24 | 2017-08-25 | N |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-08-24 | 2017-08-25 | N |
| 1) Hire only people with no legal history of abusing, neglecting or mistreating residents; or 2) report and investigate any acts or reports of abuse, neglect or mistreatment of residents. | Health | 2017-04-21 | 2017-05-08 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-04-21 | 2017-05-08 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-04-21 | 2017-05-08 | Y |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2017-04-21 | 2017-05-08 | Y |
| Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. | Health | 2017-04-21 | 2017-05-08 | Y |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2017-04-21 | 2017-05-08 | Y |
| Give residents a notice of rights, rules, services and charges. | Health | 2017-03-30 | 2017-04-10 | Y |
| 1) Provide 3 meals at regular times; 2) serve breakfast within 14 hours of dinner; and 3) offer a snack at bedtime each day. | Health | 2017-03-30 | 2017-04-10 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-03-15 | 2017-03-16 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2017-03-15 | 2017-03-16 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-02-17 | 2017-02-18 | Y |
| Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. | Health | 2017-02-17 | 2017-02-18 | Y |
| Protect each resident from all abuse, physical punishment, and involuntary separation from others. | Health | 2017-01-24 | 2017-01-25 | Y |
| Develop and implement policies for 1) screening and training employees; and the 2) prevention, identification, investigation, and reporting of any abuse, neglect, mistreatment and misappropriation of property. | Health | 2017-01-24 | 2017-01-25 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2017-01-24 | 2017-01-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2017-01-24 | 2017-01-25 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2017-01-24 | 2017-01-25 | Y |
| Ensure that each resident's 1) entire drug/medication regimen is free from unnecessary drugs; and 2) is managed and monitored to achieve highest level of well-being. | Health | 2016-11-08 | 2016-11-23 | Y |
| At least once a month, have a licensed pharmacist review each resident's medication(s) and report any irregularities to the attending doctor. | Health | 2016-11-08 | 2016-11-23 | Y |
| Maintain drug records and properly mark/label drugs and other similar products according to accepted professional standards. | Health | 2016-11-08 | 2016-11-23 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-11-08 | 2016-11-11 | Y |
| Assist those residents who need help with eating/drinking, grooming and personal and oral hygiene. | Health | 2016-11-08 | 2016-11-11 | Y |
| Properly care for residents needing special services, including: injections, colostomy, ureostomy, ileostomy, tracheostomy care, tracheal suctioning, respiratory care, foot care, and prostheses. | Health | 2016-11-08 | 2016-11-11 | Y |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2016-11-08 | 2016-11-11 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-11-08 | 2016-11-09 | Y |
| Provide housekeeping and maintenance services. | Health | 2016-11-08 | 2016-11-09 | Y |
| Provide doctor's orders for the resident's immediate care at the time the resident was admitted. | Health | 2016-11-08 | 2016-11-09 | Y |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-11-08 | 2016-11-09 | Y |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-11-08 | 2016-11-09 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-11-08 | 2016-11-09 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2016-09-29 | 2016-10-10 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-07-15 | 2016-08-04 | N |
| Provide housekeeping and maintenance services. | Health | 2016-07-15 | 2016-08-04 | N |
| Develop a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2016-07-15 | 2016-08-04 | N |
| Provide necessary care and services to maintain or improve the highest well being of each resident . | Health | 2016-07-15 | 2016-08-04 | N |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-07-15 | 2016-08-04 | N |
| Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. | Health | 2016-07-15 | 2016-08-04 | N |
| Make sure that a working call system is available in each resident's room or bathroom and bathing area. | Health | 2016-07-15 | 2016-08-04 | N |
| Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. | Health | 2016-07-15 | 2016-08-04 | N |
| Keep clinical record information safe. | Health | 2016-07-15 | 2016-08-04 | N |
| Conduct initial and periodic assessments of each resident's functional capacity. | Health | 2016-07-15 | 2016-08-04 | Y |
| Provide care by qualified persons according to each resident's written plan of care. | Health | 2016-07-15 | 2016-08-04 | Y |
| Ensure that each resident who enters the nursing home without a catheter is not given a catheter, unless medically necessary, and that incontinent patients receive proper services to prevent urinary tract infections and restore normal bladder functions. | Health | 2016-07-15 | 2016-08-04 | Y |
| Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. | Health | 2016-07-15 | 2016-08-04 | Y |
| Have a program that investigates, controls and keeps infection from spreading. | Health | 2016-07-15 | 2016-08-04 | Y |
| Keep accurate, complete and organized clinical records on each resident that meet professional standards. | Health | 2016-07-15 | 2016-08-04 | Y |
| Posted "No-smoking" signs in areas where smoking is not permitted or ashtrays provided where smoking was allowed. | Fire Safety | 2016-07-13 | 2016-08-02 | N |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2016-07-25 | 2016-07-28 | Y |
| Exits that are accessible at all times. | Fire Safety | 2016-07-13 | 2016-07-18 | N |
| Give residents proper treatment to prevent new bed (pressure) sores or heal existing bed sores. | Health | 2016-07-15 | 2016-07-15 | Y |
| Provide care for residents in a way that maintains or improves their dignity and respect in full recognition of their individuality. | Health | 2016-04-28 | 2016-05-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provide adequate supervision to prevent avoidable accidents. | Health | 2016-03-23 | 2016-04-22 | Y |
| Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. | Health | 2016-03-23 | 2016-03-26 | Y |
| Reasonably accommodate the needs and preferences of each resident. | Health | 2016-03-23 | 2016-03-24 | Y |
