Inspection Results » Briarwood Post Acute

Health Inspection on November 13, 2018 ^[1]

1. Widespread: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. (Corrected 2019-01-22)
   • Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. (Corrected 2019-01-22)
   • Administer the facility in a manner that enables it to use its resources effectively and efficiently. (Corrected 2019-01-22)

2. Pattern: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Encode each residentÂ’s assessment data and transmit these data to the State within 7 days of assessment. (Corrected 2019-01-22)
   • Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. (Corrected 2019-01-22)
   • 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 (Corrected 2019-01-22)
   • Assure the security of all personal funds of residents deposited with the facility. (Corrected 2019-01-22)
   • Employ or obtain outside professional resources to provide services in the nursing home when the facility does not employ a qualified professional to furnish a required service. (Corrected 2019-01-22)
   • Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. (Corrected 2019-01-22)
   • Assure that each residentÂ’s assessment is updated at least once every 3 months. (Corrected 2019-01-22)
   • Respond appropriately to all alleged violations. (Corrected 2019-01-22)
   • Implement a program that monitors antibiotic use. (Corrected 2019-01-22)
   • Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. (Corrected 2019-01-22)

3. Isolated: No actual harm with potential for more than minimal harm that is not immediate jeopardy

   • Provide and implement an infection prevention and control program. (Corrected 2019-01-22)
   • Provide or obtain laboratory tests/services when ordered and promptly tell the ordering practitioner of the results. (Corrected 2019-01-22)
   • Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. (Corrected 2019-01-22)
   • Ensure the resident's doctor reviews the resident's care, writes, signs and dates progress notes and orders, at each required visit. (Corrected 2019-01-22)
   • Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted (Corrected 2019-01-22)
   • Ensure the activities program is directed by a qualified professional. (Corrected 2019-01-22)
   • Ensure that the resident and his/her doctor meet face-to-face at all required visits. (Corrected 2019-01-22)
   • Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. (Corrected 2019-01-22)
   • Ensure medication error rates are not 5 percent or greater. (Corrected 2019-01-22)
   • 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. (Corrected 2019-01-22)
   • Ensure each resident receives an accurate assessment. (Corrected 2019-01-22)
   • Ensure each resident receives and the facility provides food prepared in a form designed to meet individual needs. (Corrected 2019-01-22)
   • Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. (Corrected 2019-01-22)
   • Develop and implement policies and procedures to prevent abuse, neglect, and theft. (Corrected 2019-01-22)
   • Assess the resident completely in a timely manner when first admitted, and then periodically, at least every 12 months. (Corrected 2019-01-22)

4. Widespread: No actual harm with potential for minimal harm

   • Post nurse staffing information every day. (Corrected 2019-01-22)

5. Pattern: No actual harm with potential for minimal harm

   • Properly hold, secure, and manage each resident's personal money which is deposited with the nursing home. (Corrected 2019-01-22)
   • Honor the resident's right to manage his or her financial affairs. (Corrected 2019-01-22)