BRIARWOOD POST ACUTE
Inspection History Overview
Detailed Inspection Reports
Notice: These are official CMS inspection narratives containing detailed regulatory findings. This information is not available in searchable format anywhere else online.
Fines and Penalties by Year
2022 7 penalties totaling $47,389
Fine
Fine
Fine
Fine
Fine
Fine
Fine
Health Violations by Year
2025 12 violations
Prevent the use of unnecessary psychotropic medications or use medications that may restrain a resident's ability to function.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure medication error rates are not 5 percent or greater.
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.
Provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2024 17 violations
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.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Provide enough food/fluids to maintain a resident's health.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure that residents are free from significant medication errors.
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.
Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.
Ensure each resident receives and the facility provides food that accommodates resident allergies, intolerances, and preferences, as well as appealing options.
Ensure therapeutic diets are prescribed by the attending physician and may be delegated to a registered or licensed dietitian, to the extent allowed by State law.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Keep all essential equipment working safely.
Provide and implement an infection prevention and control program.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
2023 19 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
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.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Ensure services provided by the nursing facility meet professional standards of quality.
Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
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.
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.
Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.
Provide and implement an infection prevention and control program.
Implement a program that monitors antibiotic use.
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.
Have a Compliance and Ethics Program.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public.
2022 8 violations
Plan the resident's discharge to meet the resident's goals and needs.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide and implement an infection prevention and control program.
Provide and implement an infection prevention and control program.
Reasonably accommodate the needs and preferences of each resident.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure services provided by the nursing facility meet professional standards of quality.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
2021 16 violations
Provide and implement an infection prevention and control program.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Respond appropriately to all alleged violations.
Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.
Make sure that a working call system is available in each resident's bathroom and bathing area.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
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.
Provide medically-related social services to help each resident achieve the highest possible quality of life.
Notify the resident or the residentβs representative in writing how long the nursing home will hold the residentβs bed in cases of transfer to a hospital or therapeutic leave.
Permit a resident to return to the nursing home after hospitalization or therapeutic leave that exceeds bed-hold policy.
2020 7 violations
Provide and implement an infection prevention and control program.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure that residents are fully informed and understand their health status, care and treatments.
Provide and implement an infection prevention and control program.
2019 43 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Keep residents' personal and medical records private and confidential.
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.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Assess the resident when there is a significant change in condition
Assure that each residentβs assessment is updated at least once every 3 months.
Encode each residentβs assessment data and transmit these data to the State within 7 days of assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide activities to meet all resident's needs.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Provide appropriate pressure ulcer care and prevent new ulcers from developing.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Provide enough food/fluids to maintain a resident's health.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Have a registered nurse on duty 8 hours a day; and select a registered nurse to be the director of nurses on a full time basis.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures.
2018 34 violations
Honor the resident's right to manage his or her financial affairs.
Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home.
Assure the security of all personal funds of residents deposited with the facility.
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident.
Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody.
Develop and implement policies and procedures to prevent abuse, neglect, and theft.
Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Respond appropriately to all alleged violations.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Assure that each residentβs assessment is updated at least once every 3 months.
Encode each residentβs assessment data and transmit these data to the State within 7 days of assessment.
Ensure each resident receives an accurate assessment.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Ensure the activities program is directed by a qualified professional.
Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.
Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit.
Ensure that the resident and his/her doctor meet face-to-face at all required visits.
Post nurse staffing information every day.
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.
2017 22 violations
Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.
Reasonably accommodate the needs and preferences of each resident.
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.
Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months.
Encode each residentβs assessment data and transmit these data to the State within 7 days of assessment.
Ensure a qualified health professional conducts resident assessments.
Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted
Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.
Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals.
Honor each resident's preferences, choices, values and beliefs.
Provide care and assistance to perform activities of daily living for any resident who is unable.
Provide appropriate treatment and care according to orders, residentβs preferences and goals.
Provide enough food/fluids to maintain a resident's health.
Provide safe and appropriate respiratory care for a resident when needed.
Provide safe, appropriate dialysis care/services for a resident who requires such services.
Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.
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.
Have a plan that describes the process for conducting QAPI and QAA activities.
Provide and implement an infection prevention and control program.
Make sure that a working call system is available in each resident's room or bathroom and bathing area.