Briarwood Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that safe cleaning practices, humidification, dispensation of oxygen and storage of respiratory equipment was maintained. This deficiency affected four residents (R77, R82, R84 and R89) of four residents reviewed for respiratory standards of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to 1) Ensure proper storage of medications for Resident #23 and Resident #112; 2) Ensure that medication carts and treatment carts were secured; 3) Ensure that expired medications were disposed of; 4) Ensure that a medication cart was in sanitary condition; and 5) Ensure that medication cart keys, which included narcotic keys, were not shared between nurses, for three of six medication carts, one of three medication storage areas, one treatment cart and one wound care cart reviewed for storage of medications, supplies and narcotics.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that menus and/or food preferences were followed for three residents (#12, #13, #84) of three residents reviewed for preferences and nine residents observed during the dining task.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain best practices in the food service area, resulting in the potential to spread food borne illness to all residents who consume food from the kitchen.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure appropriate backflow prevention was installed at plumbing fixtures, resulting in the potential for contamination to the water supply, affecting all residents.

Inspectors wroteBased on observation, interview and record review the facility failed to assess and monitor for potential changes in condition of a hydrocele (fluid-filled sac in the scrotum that causes swelling) for one resident (Resident #97) of one resident reviewed for assessment and monitoring. Findings Include:Resident #97:On 6/1/2026 at 10:30 AM, as Nurse N entered the room to complete vitals and assess Resident #97's roommate, prior to her assessment she observed Resident #97 sitting up on the side of the bed and it appeared he was attempting to get up unassisted. Resident #97 only had on white shirt sleeve T-shirt and a large hydrocele about the size of a melon was observed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the prescribed nutritional formula was consistently available and that the quality was maintained. This failure affected one resident (Resident #106) of one resident reviewed for enteral nutrition standards of care.

Inspectors wroteBased on the interview and record review, the facility failed to ensure the adequate competency and verification of skills for one (1) certified nursing assistant of five (5) certified nursing assistants reviewed for completion of annual 12 contact hours, and the competency/training checklist required by the facility was completed before being taken off the training schedule for resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to identify, implement and follow enhanced barrier precautions (EBP) for a resident identified with qualifying medical needs for one resident (Resident #106) (R106) of three residents reviewed for infection prevention.

Inspectors wroteThis Citation pertains to Intake Number 2988534. Based on interview and record review, the facility failed to ensure coordination of care with external care providers for one resident (Resident #701) of three residents reviewed.

Inspectors wroteThis Citation pertains to Intake Number 2986995. Based on interview and record review, the facility failed to correctly assess the wound status of one resident (Resident #702) upon admission of three residents reviewed, resulting in a lack of timely and comprehensive identification, and the assessment and care of an alteration in skin integrity.

Inspectors wroteThis Citation pertains to Intake Number 2986995. Based on interview and record review, the facility failed to identify, comprehensively assess, and document nutritional/hydration needs and intake for one resident (Resident #702) of three residents reviewed for quality of care resulting, in a lack of identification of risk for dehydration, timely initiation of a Health Care Provider (HCP) ordered diet, documentation of fluid intake, and a decline in health status.

Inspectors wroteThis Citation pertains to Intake Number 2709347. Based on interview and record review, the facility failed to implement and operationalize policies and procedures for advance care planning for three residents (#701, #704, and #706) of three residents reviewed, resulting in the lack of timely determination of decision-making capacity and arranging appropriate and legal representation for Resident #701 and Resident #706 and the lack of current guardianship documentation for Resident #704.

Inspectors wroteThis Citation pertains to Intake Number 2709347. Based on observation, interview and record review, the facility failed to implement and operationalize policies and procedures for the care of pressure ulcers for two residents (#'702 and #703) of three residents reviewed, resulting in a lack of accurate documentation of care and implementation of planned interventions.

Inspectors wroteThis Citation Pertains to Intake # 2676612. Based on observation, interview and record review, the facility failed to ensure that 1) the sink used for hand hygiene in the kitchen maintained a hot water temperature of at least 85 degrees Fahrenheit and 2) the chemical strips used to test the dish machine were not expired, resulting in the potential for the spread of foodborne illness to all Residents receiving meal service from a census of 99 residents. Kitchen hand washing sinkOn 12/5/2025 at 9:00 AM, during a tour of the Kitchen with Dietary Supervisor B, a sink for employee hand hygiene was noted near the entrance to the kitchen from the service hall. Upon use of the hot water, it was identified to be very cold. The Dietary Supervisor B was asked about the hot water being cold, as she was observed performing hand hygiene and she said sometimes it had to run a bit for it to warm up. [...]

Inspectors wroteThis Citation Pertains to Intake# 2678077Based on observation, interview and record review the facility failed to develop and implement a comprehensive care plan for one resident (#6) of 3 residents reviewed for wound care, resulting in Resident #6 lacking a care plan for a right leg brace. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #6 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: history of right knee replacement and post-surgical right knee infection, reduced circulation right leg, heart disease, and arthritis in knees. The resident had full cognitive abilities and made her own decisions. On 12/4/2025 at 10:00 AM, Resident #6 was observed sitting on the bed in her room, with her right lower leg wrapped in a dressing with a right lower leg brace on. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to: (1) Ensure proper cleaning of therapy gym equipment for all residents utilizing the equipment; (2) Ensure the timely removal of Resident #2's soiled gown, blanket and linen , (3) Ensure the timely disposal of daily hygiene products of a discharged resident (Resident #15) and the cleaning of the room prior to admittance of a new resident and (4) Ensure the decluttering of residents' items throughout the rooms on the 100 Hall. Findings Include: Therapy Gym During initial tour a resident shared a peddle on the bike in the therapy room gym, was not safe for residents to utilize and requested it be observed for functionality and safety. On 4/24/2025 at 1:10 PM, an observation was conducted of the facility therapy gym. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the clinical staff posting was completed and available for review for multiple days from October 2024- April 2025, resulting in the inability of residents and visitors to know what clinical staff were working on those days. Findings Include: FACILITY Sufficient and Competent Nurse Staffing On 4/24/2025 at 9:17 AM, the Administrator was asked where the posted nurse staffing was located. She said the document was on the wall near the entry to the facility. Upon review of the posted document it said Tuesday, 4/24/2025. The Administrator, viewed the document; discussed with her the dated was correct but the day was wrong. It was not Tuesday; It was Thursday. She said the staff member N responsible for completing the document would correct it. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide timely assistance with activities of daily living (ADL) including showers, nail care and hair care for two residents ( #52 and #139), from a sample of 20 residents. Findings Include: Resident #52: Activities of Daily Living On 4/23/2025 at 1:15 PM, Resident #52 was observed lying in bed in her room. She said she had itching on her face and leg and said it was horrible. She said they gave her something for the itching, but the itching would come back frequently. A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, depression, anxiety, diabetes, chronic kidney disease, arthritis, blindness right eye and hypothyroidism. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to monitor weights timely for a Resident who had a hospitalization and return with a Percutaneous Endoscopic Gastrostomy ) (PEG) tube for feeding for one resident (Resident #62) of two residents reviewed for weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to 1) Monitor a PICC (Peripherally Inserted Central Catheter) line placement for Resident #8; 2) Monitor antibiotic administration and notify the physician of three missed doses for Resident #289; and 3) Document the clinical rationale for an increase in the Vancomycin dose for Resident #84 for three of four residents reviewed for PICC lines. Findings Include: Resident #84: On 4/23/2024 at approximately 3:35 PM, Resident #84 was observed ambulating down the hallway into her room. She stated she developed osteomyelitis and is here for IV antibiotics. On 4/24/2025 at approximately 9:30 AM, a review was conducted of Resident #84's medical records and it indicated she readmitted to the facility on [DATE] with diagnoses that included, Osteomyelitis, Diabetes, Asthma, Heart Disease and Atrial Fibrillation. [...]

Inspectors wroteBased on interview and record review, the facility failed to 1) Identify a medication order discrepancy and 2) Address the pharmacy monthly medication regimen review timely for one resident (Resident #18) of five residents reviewed for medication regimen review, resulting in a medication ordered with the previous order not discontinued.

Inspectors wroteBased on interview and record review, the facility failed to 1) Obtain a signed consent for treatment with antipsychotic medications for Resident #52 and 2) Prevent the duplication of medications administered to Resident #18. Findings Include: Resident #52: Unnecessary Meds, Psychotropic Meds, and Med Regimen Review A record review of the Face sheet and Minimum Data Set/MDS assessment indicated Resident #52 was admitted to the facility on [DATE] and readmitted on [DATE] with diagnoses: Dementia, depression, anxiety, diabetes, chronic kidney disease, arthritis, blindness right eye and hypothyroidism. The MDS assessment dated [DATE] revealed the resident had moderate cognitive loss with a Brief Interview for Mental Status/BIMS score of 10/15 and the resident was independent with most care but needed some assistance and oversight with bathing/showering. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 3 medication carts (Halls 300, 400 and 500) of 4 medication carts observed were maintained clean and sanitized, free of crushed pills, pieces of loose papers and dust in the drawers. Findings Include: Observation of facility medication carts done on 4/23/25 starting at 10:55 a.m., revealed the following: 500 Hall Med Cart: Observation was done on 4/23/25 at approximately 10:40 a.m., accompanied by Nurse, RN B revealed the following: -The second and third drawer's had pieces of crushed medications/meds and paper on the bottom back. During an interview done on 4/23/25 at 10:45 a.m., Nurse B stated Third shift cleans it, but we can all clean it. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain food preparation and kitchen equipment in a sanitary and good working condition, resulting in an increased likelihood for food borne illnesses with hospitalization, and cross contamination affecting 82 residents who consumed oral nutrition from the facility kitchen and ice machine of a total census of 84 residents.

Inspectors wroteThis Citation pertains to Intake Number MI00146446. Based on interview and record review, the facility failed to ensure that a complete nursing assessment was done after a condition change (a fall at the facility on 7/2/24) for one resident (Resident #101) of 3 residents reviewed for assessing/monitoring after a change in condition (a decline in therapy due to increased pain), resulting in incomplete nursing and physician documentation, and delayed hospitalization with a CT (Computed Tomography). Findings Include: Resident #101: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide appropriate skin care to prevent the development and failed to implement adequate interventions to avoid the worsening of unstageable pressure ulcer for one resident (Resident #69) of five sampled residents reviewed for pressure ulcer out of a total sample of 18 residents, resulting in the development and worsening of a facility-acquired pressure ulcer resulting in severe pain and suffering, and the potential for infection, delayed wound healing and a deterioration in health status.

Inspectors wroteBased on observation, interview and record review, the facility 1.) Failed to ensure that food products were properly labeled with an Opened and/or Use by date and dispose of expired food items; 2.) Failed to monitor/document temperatures of a refrigerated unit; 3.) Failed to properly wash and dry cookware/bakeware/food containers before stacking/storage; and 4.) Failed to maintain sanitary cooking equipment, resulting in the potential contamination of food, bacterial harborage and the increased potential for food borne illness. This deficient practice had the potential to affect all residents who consume food prepared in the kitchen with a census of 73.

Inspectors wroteResident #6 Activities of Daily Living Resident #6 (R6) on 04/15/24 02:20 PM, was observed lying on his bed with his wife visiting on the bedside. R6 was observed wearing a white T-shirt that appeared one size larger on him and a gray jogging pants that was too short and too tight for his size. When asked if he felt comfortable, he did not answer. R6 wife explained that R6 is very hard of hearing and may not have heard the question. R6 was observed with beard growth all over his face. The hair growth stood out because it was gray in color, on the R6's jaw, chin, upper lip, lower lip, cheeks and neck. Meanwhile, R6 wife was holding on to a shaving cream and razor. When asked, R6 wife revealed that she and her daughter had been taking turns shaving R6 beard and was not sure if the facility does it or them. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received their mail on Saturdays, resulting in residents not being able to exercise their right to receive mail and access communication. Findings Include: FACILITY On 4/16/24 at 2:30 PM, during an interview with a Confidential Group of Residents, when asked if the residents received Mail on Saturdays, the residents stated, The Mail doesn't run on Saturday. The Mail lady has weekends off. During further discussion, the residents said they did not receive mail on Saturday but did receive mail during the week. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1.) Resident rooms were clean and in good repair and free of chipped paint and broken tiles; 2) Resident lift equipment was clean; and 3.) Wash basins were properly stored and labeled, affecting room numbers #101, 103, 104, 105, 203, 204, 209, and 211, and residents using the sit-to-stand lift, resulting in an unsanitary environment, potential spread of infection, and dissatisfaction with living conditions.

Inspectors wroteBased on observation, interview and record review, the facility failed to properly dispose of wasted medications and secure treatment carts that contained prescription treatment medications and medical supplies, resulting in the potential for drug diversion and ingestion of medicated substances.

Inspectors wroteBased on interview and record review, the facility failed to ensure that ongoing surveillance of infectious illnesses for employees was maintained, documented, analyzed and reported, resulting in the potential for a lack of guidance to ensure compliance with infection control standards of practice and exposure to infectious organisms, which could lead to an unidentified outbreak. Findings Include: FACILITY Infection Control On 4/17/24 at 10:20 AM, during a review of the Infection Prevention and Control Program with Infection Preventionist/IP H, he was asked about surveillance for employee illnesses. The IP said the facility had an employee call in log, that identified staff call-ins from work. He said during the morning Interdisciplinary Team Meeting, he would look at the employee call in logs. [...]

Inspectors wroteBased on interview and record review, the facility failed to review and revise care plans with resident changes to ensure interventions necessary for care and services were provided for one resident (Resident #45) reviewed for care plans, resulting in the potential for unmet care needs. Findings Include: Resident #45 Activities of Daily Living On 4/15/24 at 12:04 PM, during a tour of the facility a Confidential Resident stated, Resident #45, Never bathes/showers and it makes the room smell. The Confidential Person said they couldn't bring visitors in because of that. On 4/15/2024 at 12:15 PM, Resident #45 was observed lying in bed, awake with soiled clothes with brown stains. The resident appeared disheveled, his hair unwashed and the bed linens were soiled with brown stains. There were papers all over the bed. The resident did not readily answer questions. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that medications were administered per the physician's order for two residents (Resident #53 and Residednt #273) resulting in multiple medication administrations not being documented in the Electronic Health Record (EHR)(Resident #53) and a lidocaine patch not being removed prior to administering another patch(Resident #273) with potential for adverse reactions and skin irritation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that proper communication/documentation of Hospice services were provided to one resident (Resident #37) of two residents reviewed for Hospice services, resulting in the lack of receipt of progress notes/assessments to resident medical record with ineffective communication and collaboration of services between the facility and hospice service, lack of residents and staff aware of hospice schedule and the potential for unmet care needs.