Inspection Reports for
Briarwood Senior Living

The visit was complaint-related due to concerns about hospice care residents not being evacuated during fire drills and lack of proper documentation and training. The complaint was substantiated with multiple deficiencies found.

The facility failed to properly evacuate a hospice resident during fire drills and lacked required physician certification and informed consent for non-evacuation. Fire drill records were inaccurate, and staff were not properly trained on evacuation procedures. The resident's assessment and support plan did not address evacuation exclusion. Corrective actions including physician evaluations, staff re-education, audits, and updated documentation were implemented.

The facility was found to have three deficiencies related to unlocked poisonous materials, unlabeled leftover food, and medication administration errors. The submitted plan of correction was accepted and fully implemented by 12/19/2025.

The facility was found to have fully implemented its submitted plan of correction. Two deficiencies were noted: ice and snow obstruction on exterior exits, and an incomplete annual medical evaluation for a resident, both of which were corrected by the specified dates.

The inspection identified several deficiencies including an unsecured enabler bar on a resident's bed, missing gauze in the first aid kit, icy exterior stairs and deck, obstructed egress route by a rock salt dispenser, incorrect resident count in the fire department notification, and incomplete documentation in a resident's support plan regarding enabler bar use. All deficiencies had plans of correction submitted and were implemented by 01/29/2024.

The facility was found to have fully implemented the submitted plan of correction related to resident abuse reporting, abuse incidents, and indoor temperature violations. Staff were retrained, and corrective actions such as suspension and termination of a staff member and installation of a baseboard heater were completed.

The facility was found to have multiple deficiencies including contract refund terms, lack of CPR-trained staff during certain periods, missing water testing, snow removal issues, obstructed egress, improperly timed fire drills, and overdue annual medical evaluations. Plans of correction were accepted and implemented by January 2023.

The inspection identified several deficiencies including undated carbon monoxide detector batteries, lack of documentation for quality management meetings, insufficient administrator staffing hours, absence of CPR certified staff overnight, failure to notify the fire department after change of ownership, missing fire safety inspection documentation, and menus not posted sufficiently in advance. Plans of correction were accepted and implemented for all deficiencies.

No inspection findings are reported in this document. It confirms issuance of a regular license and states that enforcement action will be taken if noncompliance is found during future inspections.

The submitted plan of correction was determined to be fully implemented. Two deficiencies were identified related to hot water temperature exceeding 120°F and missing exit signage, both of which were corrected with documented evidence submitted and reviewed.

The facility was found to be in substantial compliance with applicable regulations, but several citations were noted including missing grab bars in bathrooms, lack of evacuation diagrams in a remodeled section, expired fire extinguisher inspections, and missing exit signs. All deficiencies were corrected or had plans of correction implemented.