Inspection Reports for Briar Hill Rest Home

The State Agency conducted an Annual Recertification survey along with one Complaint Investigation at the facility from 2026-01-20 through 2026-01-22 to assess compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with requirements, citing deficiencies related to required postings, professional standards for enteral nutrition services, and activities of daily living care. No citations were related to the complaint investigation.

The complaint investigation (CI MS #2684586) was conducted concurrently but no citations or deficiencies were related to the complaint.

The State Agency conducted an Annual Recertification survey along with one Compliant Investigation at the facility from 2026-01-20 through 2026-01-22 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with licensure requirements related to activities of daily living, specifically failing to provide necessary grooming assistance to one resident according to her preferences. No citations were related to the complaint investigation.

The complaint investigation (CI MS # 2684586) was conducted concurrently but resulted in no citations or findings.

The survey was conducted to assess compliance with the Life Safety Code (LSC) and emergency preparedness requirements.

The facility met all applicable provisions of the 2012 Edition of the Life Safety Code and all Federal, State, and local emergency preparedness requirements. No deficiencies were cited during this survey.

The State Agency conducted a desk review of information related to the Licensure survey completed on 2025-11-05 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the State Agency recommended the facility be placed back in compliance effective 2025-12-01.

The State Agency conducted an annual recertification survey at the facility from 11/3/2025 to 11/5/2025 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with infection control standards, specifically failing to maintain effective infection control practices including staff not wearing gowns during catheter care and failure to perform proper hand hygiene during care for residents on enhanced precautions.

The State Agency conducted a Complaint Investigation (CI), MS #480760, at the facility on 8/28/25 following a Facility Reported Incident (FRI) alleging neglect when a resident's foot was reportedly pulled under her wheelchair while being ambulated by a Certified Nurse Aide, resulting in a fracture.

During the survey, the State Agency determined the facility was in compliance with Medicare and Medicaid participation requirements and no deficiencies were cited.

Complaint Investigation MS #480760 was substantiated as the facility was found in compliance with no deficiencies cited related to the allegation of neglect involving a resident's foot injury.

The State Agency conducted a Complaint Investigation at the facility on 8/28/25 regarding a Facility Reported Incident involving an allegation of neglect when a resident's foot was reportedly pulled under her wheelchair while being ambulated by a Certified Nurse Aide, resulting in a fracture.

The survey determined the facility was in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #480760 was substantiated as the facility was found in compliance with no deficiencies cited.

The State Agency conducted a follow-up revisit at the facility on 5/06/25 related to the complaint survey conducted from 4/07/25 through 4/09/25.

The State Agency found the facility to be in compliance with the requirements of participation in Medicare and Medicaid and recommends the facility be placed back in compliance effective 4/30/25.

Follow-up revisit related to a complaint survey conducted from 4/07/25 through 4/09/25; facility found in compliance.

The State Agency conducted a follow-up revisit at the facility on 05/06/2025 related to the complaint survey conducted from 04/07/2025 through 04/09/2025.

The State Agency found the facility to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements, recommending the facility be placed back in compliance effective 04/30/2025.

The visit was related to a complaint survey conducted earlier in April 2025; the follow-up found the facility in compliance.

The State Agency conducted five complaint investigations at the facility from 4/7/25 to 4/9/25 regarding quality of care, neglect, abuse, elopement, staffing, feeding assistance, dignity, call lights, infection control, turning and reposition, bowel and bladder, accidents, and hazards.

The facility was found not in compliance with Medicare and Medicaid participation requirements due to neglect related to a resident transfer incident where staff failed to properly assist during use of a full body lift, resulting in injury to one resident. The facility implemented corrective actions including staff suspension, in-services, audits, and termination of involved CNAs.

Five complaint investigations were conducted (CI MS #28147, #28148, #28166, #28348, #28536) covering issues such as quality of care, neglect, abuse, elopement, staffing, feeding assistance, dignity, call lights, infection control, turning and reposition, bowel and bladder, accidents, and hazards. The facility was cited related to CI MS#28536.

The State Agency conducted a Complaint Investigation from 2025-04-07 to 2025-04-09 regarding multiple complaints including quality of care, neglect, abuse, elopement, staffing, feeding assistance, dignity, call lights, infection control, turning and reposition, bowel and bladder, accidents, and hazards.

The facility was found not in compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. A Level III deficiency was cited for failure to ensure a resident's right to be free from neglect when staff failed to properly assist during a full body lift transfer, resulting in injury and hospitalization of one resident. The facility implemented corrective actions including staff suspensions, in-services, audits, and reassessments.

The complaint investigation involved multiple complaint numbers (CI MS #28147, #28148, #28166, #28348, #28536) covering issues such as quality of care, neglect, abuse, elopement, staffing, feeding assistance, dignity, call lights, infection control, turning and reposition, bowel and bladder, accidents, and hazards. The facility was found non-compliant related to CI MS#28536.

The State Agency conducted a complaint investigation related to inappropriate feeding assistance with weight loss, quality of life, and quality of care.

The facility was found to be in compliance with Medicare and Medicaid participation requirements, and no deficiencies were cited.

Complaint investigation (CI MS #27398) related to inappropriate feeding assistance with weight loss, quality of life, and quality of care; no deficiencies were cited.

The inspection was conducted as a complaint investigation related to Quality of Care/Treatment concerning inappropriate feeding assistance and Quality of Life.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint investigation CI MS# 27398 regarding Quality of Care/Treatment related to inappropriate feeding assistance and Quality of Life. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a desk review of information related to the annual survey completed on 2024-08-15 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The facility was confirmed to be in compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm, and the agency recommended the facility be placed back in compliance effective 2024-09-25.

The State Agency conducted a desk review of information related to the annual survey completed on 2024-08-15 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficient practices and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2024-09-25.

The State Agency conducted an annual recertification survey and complaint investigations at the facility from 08/13/24 through 08/15/24 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with multiple requirements including resident abuse and dignity, care plan implementation, accident hazards, nurse staffing posting, medication error rates, menu portion sizes, and food safety practices. Several deficiencies were cited related to these issues.

The survey included complaint investigations related to resident abuse and dignity (CI MS #25862, #25884), accidents related to falls (CI MS #25621), and physical abuse (CI MS #26867). Some complaints were substantiated with citations (F602, F656, F689), while others had no deficient practices cited.

The State Agency conducted an annual recertification survey and complaint investigations at the facility from 08/13/24 through 08/15/24 to assess compliance with Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements.

The facility was found not in compliance with several standards including employee tuberculosis testing, residents' rights, accident prevention, safe food handling, and food preparation. Deficiencies included failure to follow-up on annual TB screening for employees, failure to ensure a resident was free from exploitation, failure to ensure safe two-person transfers, improper food storage and labeling, and inconsistent food portion sizes.

The complaint investigations included allegations of resident abuse and dignity violations related to a Facility Reported Incident (FRI) involving Resident #12. The investigation confirmed exploitation through a social media video posted by a CNA, leading to termination of the employee.

The survey was conducted to assess the facility's compliance with emergency preparedness requirements and the Life Safety Code provisions.

The facility met all applicable Federal, State, and local emergency preparedness requirements with no deficiencies cited. Additionally, there were no Life Safety Code deficiencies found during this survey.

The State Agency conducted a Complaint Investigation at the facility regarding the allegation of an unnecessary fall.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. No deficiencies were cited.

Complaint Investigation MS #24158 regarding an allegation of unnecessary fall; no deficiencies cited.

The State Agency conducted a complaint investigation regarding a fall with injury at the facility.

During the survey, the facility was found to be in compliance with Medicare and Medicaid requirements, and no deficiencies were cited.

Complaint Investigation (CI MS #24158) was investigated regarding a fall with injury and found no deficiencies.

The State Agency conducted a Complaint Investigation at the facility related to Rehabilitation Services, Neglect, Injury of Unknown Origin, Grooming, Staffing, and Care not received per the Physician's Orders.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm and state licensure requirements. There were no deficiencies cited.

Complaint Investigation MS #22317 was conducted. The complaint involved Rehabilitation Services, Neglect, Injury of Unknown Origin, Grooming, Staffing, and Care not received per Physician's Orders. The complaint was not substantiated as no deficiencies were cited.

The State Agency conducted a complaint investigation related to Rehabilitation Services, Neglect, Injury of Unknown Origin, Grooming, Staffing, and Care not received per the Physician's Orders.

The facility was found to be in compliance with the requirements of participation in Medicare and Medicaid, and there were no deficiencies cited.

Complaint Investigation (CI MS #22317) related to Rehabilitation Services, Neglect, Injury of Unknown Origin, Grooming, Staffing, and Care not received per the Physician's Orders. No deficiencies were cited.

The State Agency conducted a desk review of information related to a complaint survey completed on 2023-01-19 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation for Institutions for the Aged or Infirm.

The visit was related to a complaint survey completed on 2023-01-19. The facility was found to be in compliance based on the desk review.

The State Agency conducted a desk review of information related to the annual survey completed on 2023-01-19 to verify corrective measures taken by the facility.

The facility provided information confirming corrective actions were implemented to address deficiencies and sustain compliance with Medicare and Medicaid requirements. The State Agency recommended the facility be placed back in compliance effective 2023-02-15.

The State Agency conducted a complaint investigation at the facility for two complaints, MS #20738 and MS #20739, from 2/28/23 through 3/01/23.

The facility was found to be in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. No deficiencies were cited related to Quality of Care, pressure sore precautions, notification, incontinent care, Resident Assessment, or Nursing Services.

The investigation covered two complaints: MS #20738 regarding Quality of Care related to pressure sore precautions, notification, and incontinent care, and Resident Assessment; and MS #20739 regarding Nursing Services. Both complaints resulted in no deficiencies cited.

The State Agency conducted a complaint investigation at the facility for two complaints, MS #20738 and MS #20739, from 2/28/23 through 3/01/23. The investigation focused on Quality of Care related to pressure sore precautions, notification, incontinent care, Resident Assessment, and Nursing Services.

The investigation found no deficiencies related to complaint MS #20739 for Nursing Services. However, the facility remains out of compliance due to deficiencies cited on the annual recertification survey completed on 1/19/23.

Complaint MS #20738 was investigated for Quality of Care related to pressure sore precautions, notification, incontinent care, and Resident Assessment. Complaint MS #20739 was investigated for Nursing Services and cited no deficiencies.

The State Agency conducted an annual recertification survey and complaint investigation at the facility from 01/17/23 through 01/19/23.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited related to the complaint investigation.

The complaint investigation (CI) MS #20293 was unable to determine noncompliance and no deficiencies were cited related to the complaint.

The State Agency conducted an annual recertification survey and complaint investigation at the facility from 01/17/2023 through 01/19/2023 to assess compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance due to a deficiency related to incontinent care that could lead to urinary tract infections for one resident. No deficiencies were cited related to the complaint investigation.

The complaint investigation (MS #20293) was unable to determine noncompliance and no deficiencies were cited related to the complaint.

The State Agency conducted an annual recertification survey and complaint investigation at the facility from 01/17/23 through 01/19/23.

The facility was found to be in compliance with the Minimum Standards for Institutions for the Aged or Infirm, state licensure requirements. No deficiencies were cited related to the complaint investigation.

The complaint investigation (MS #20293) was unable to determine noncompliance and no deficiencies were cited related to the complaint.

The State Agency conducted an annual recertification survey and complaint investigation at the facility from 01/17/2023 through 01/19/2023.

The facility was found not in compliance with Medicare and Medicaid participation requirements and was cited for deficiency F690. No deficiencies were cited related to the complaint investigation.

Complaint investigation MS #20293 was conducted but no deficiencies were cited related to the complaint and the State Agency was unable to determine noncompliance for the complaint.

The inspection was conducted to assess compliance with the 2012 Edition of the Life Safety Code (LSC) of the National Fire Protection Association (NFPA).

The facility met the applicable provisions of the 2012 Edition of the Life Safety Code, and no LSC deficiencies were cited during this survey.

The survey was conducted to assess the facility's compliance with Federal, State, and local emergency preparedness requirements.

The facility met all applicable emergency preparedness requirements with no deficiencies cited.

The State Agency conducted a desk review related to a complaint survey completed on 2022-10-05 to determine compliance with Minimum Standards of Operation for Institutions for the Aged or Infirm.

The information provided by the facility confirmed compliance with the Minimum Standards of Operation, and the facility was recommended to be placed back in compliance effective 2022-11-15.

The visit was complaint-related, reviewing information from a complaint survey completed on 2022-10-05. The facility was found in compliance and the complaint was effectively resolved.

The State Agency conducted a desk review of information related to a complaint survey completed on 2022-10-05 to verify corrective measures taken by the facility.

The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The facility was recommended to be placed back in compliance effective 2022-11-15.

The visit was related to a complaint survey completed on 2022-10-05. The desk review confirmed corrective actions and compliance.

The State Agency conducted a Complaint Investigation from 10/03/22 through 10/05/22 related to Nursing Services, Resident Abuse (Verbal), Pharmaceutical Services, Quality of Care/Treatment, Resident Neglect, Resident Rights, and Quality of Care/Treatment concerning call lights not answered timely, resident grooming, and care/services not received per physician orders.

The facility was found in compliance with Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm. The agency substantiated verbal abuse of one resident and misappropriation of medication for four residents. The facility terminated the involved nurse and implemented corrective actions including staff in-services, audits, and increased monitoring to prevent recurrence.

The complaint investigation was triggered by multiple complaints including verbal abuse and medication misappropriation. The verbal abuse complaint was substantiated against Registered Nurse #1 who was terminated. The medication diversion complaint was substantiated against Licensed Practical Nurse #1 who was terminated after investigation and positive drug screen for opioids without valid prescription.

The State Agency conducted a Complaint Investigation from 10/03/22 through 10/05/22 related to Nursing Services, Resident Verbal Abuse, Pharmaceutical Services, Quality of Care/Treatment, Resident Neglect, Resident Abuse, Resident Rights, and Quality of Care/Treatment concerning call lights not answered timely, resident grooming, and care/services not received per physician orders.

The facility was found not in compliance with Medicare and Medicaid participation requirements. The investigation substantiated misappropriation of medication affecting four residents and resident verbal abuse involving one resident. The facility terminated involved staff and implemented corrective actions including staff education and monitoring.

The complaint investigation included multiple allegations: Nursing Services, Resident Verbal Abuse, Pharmaceutical Services, Quality of Care/Treatment, Resident Neglect, Resident Abuse, Resident Rights, and Quality of Care/Treatment. The agency substantiated misappropriation of medication and resident verbal abuse but did not substantiate other allegations.

The State Agency conducted a follow-up/revisit survey on 04/01/22 at the facility for the Substandard Quality of Care cited on a complaint survey conducted 01/27/22 through 01/28/22.

The State Agency determined the facility was in compliance with the Mississippi Regulations for Minimum Standards for Institutions for the Aged or Infirm.

The visit was a follow-up to a complaint survey citing Substandard Quality of Care; the facility was found in compliance upon follow-up.

The State Agency conducted a follow-up/revisit survey on 04/01/22 at the facility for the Substandard Quality of Care cited on a complaint survey conducted 01/27/22 through 01/28/22.

The State Agency determined the facility was in compliance with the requirements for participation in Medicare and Medicaid at the time of the follow-up survey.

The follow-up survey was conducted due to a Substandard Quality of Care citation from a prior complaint survey conducted 01/27/22 through 01/28/22.

The State Agency conducted a complaint investigation at the facility for complaint investigations MS #18285 and MS #18459 from 1/27/22 through 1/28/22. The investigation was triggered by concerns related to resident safety and prevention of accidents, specifically a fall resulting in serious injury.

The facility was found not in compliance with Minimum Standards of Operation and state licensure requirements related to accidents. The facility failed to ensure two staff members were involved in a mechanical lift transfer for a resident requiring two-person assistance, resulting in Resident #2 falling from the lift and sustaining a femur fracture. The aide responsible was suspended and later terminated. The facility implemented corrective actions including staff training, competency checkoffs, and ongoing monitoring to prevent recurrence.

The complaint investigation MS #18459 was substantiated for resident safety and prevention of accidents related to a fall resulting in serious injury. Complaint investigation MS #18285 was not substantiated for physician notification and quality of care.

The State Agency conducted a complaint investigation at the facility for two complaint investigations (CI MS #18285 and CI MS #18459) from 1/27/22 through 1/28/22. The investigation was triggered by allegations related to resident safety and quality of care.

The facility was found not in compliance with Medicare and Medicaid participation requirements. The complaint investigation substantiated a fall resulting in a serious injury due to failure to follow the care plan for mechanical lift transfers. Deficiencies were cited related to failure to ensure two-person assistance during mechanical lift transfers and improper sling placement, resulting in a resident fall and femur fracture.

The complaint investigation substantiated CI MS #18459 for resident safety and prevention of accidents related to a fall which resulted in a serious injury. CI MS #18285 was not substantiated for physician notification and quality of care.

The State Agency conducted a complaint survey at the facility on 10/29/21 based on complaints MS #18237 and MS #18082.

The facility was found to be in compliance with regulations with no deficiencies cited. Both complaints were not substantiated.

Complaint MS #18237 was not substantiated for Staff Improperly Qualified, Care/Services Not Received, or Infection Control. Complaint MS #18082 was not substantiated for Sanitation-Dietary Services, Physical Environment-Facility Not Clean, Quality of Care, or Inappropriate Feeding Assistance.

The State Agency conducted a complaint survey at the facility on 10/29/21 to investigate two complaint cases, MS #18237 and MS #18082.

The facility was found to be in compliance with regulations for participation in CMS. Both complaints were not substantiated and no deficiencies were cited.

Complaint MS #18237 was not substantiated for Staff Improperly Qualified, Care/Services Not Received, or Infection Control. Complaint MS #18082 was not substantiated for Sanitation-Dietary Services, Physical Environment-Facility Not Clean, Quality of Care, or Inappropriate Feeding Assistance.

The State Agency conducted a desk review related to a complaint investigation that was conducted on 2021-05-26 to verify corrective measures taken by the facility.

The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Minimum Standards of Operation and state licensure requirements. The facility was recommended to be placed back in compliance effective 2021-07-19.

The visit was related to a complaint investigation conducted on 2021-05-26. The facility was found to have corrected the deficiencies and was recommended to be placed back in compliance.

The State Agency conducted a desk review related to a complaint investigation that was conducted on 2021-05-26.

The information provided by the facility confirmed that measures were put in place to correct the deficient practice and sustain compliance with Medicare and Medicaid requirements. The facility was recommended to be placed back in compliance effective 2021-07-19.

Complaint investigation conducted on 2021-05-26; the facility was found to have corrected the deficient practice and sustained compliance.

The State Agency conducted a complaint survey based on three complaint investigations (CI MS #16700, CI MS #17180, and CI MS #17252) to determine compliance with Minimum Standards for Institutions for the Aged or Infirm.

The facility was found not in compliance due to failure to maintain minimum staffing ratios of 2.8 direct nursing care hours per resident per day for two days in March 2020 and 12 days in September 2020. Complaint CI MS #17180 was substantiated citing staffing ratio deficiencies, while complaints related to a fall with head injury and alleged abuse and neglect were not substantiated.

Complaint Investigation (CI) MS #17180 was substantiated for staffing ratio deficiencies. CI MS #16700 related to a fall with head injury and CI MS #17252 for alleged abuse and neglect were not substantiated.

The State Agency conducted a complaint survey on 5/26/2021 based on complaints related to falls with head injury and alleged abuse and neglect.

The facility was found not in compliance with Medicare and Medicaid participation requirements. Three residents were reviewed for abuse and neglect incidents. Deficiencies were cited for failure to timely report alleged abuse/neglect to appropriate State agencies and failure to thoroughly investigate alleged abuse/neglect incidents. No thorough investigations or timely reports to State agencies were documented for the incidents involving Residents #1, #2, and #3.

Complaint Investigation (CI) MS #16700 related to a fall with head injury and CI MS #17252 for alleged abuse and neglect were not substantiated, but deficiencies were cited. CI MS #17180 was substantiated with no Federal deficiencies cited.

The State Agency conducted a COVID-19 Focused Infection Control Survey to assess compliance with infection control regulations and implementation of recommended practices by CMS and CDC.

The facility was found in compliance with infection control regulations and had implemented recommended COVID-19 practices. No concerns were noted during the review of infection prevention policies, PPE availability, staffing, visitor restrictions, and reporting of COVID-19 cases.

A COVID-19 Focused Emergency Preparedness Survey was conducted by CMS to assess compliance with infection control and emergency preparedness regulations related to COVID-19.

The facility was found to be in compliance with federal infection control regulations and had implemented recommended CMS and CDC practices to prepare for COVID-19. No concerns were noted during the review of infection prevention policies, PPE availability, staffing, visitor restrictions, and reporting of COVID-19 cases.

The State Agency conducted a COVID-19 Focused Infection Control Survey along with a Complaint Investigation (CI# MS16752) on 9/14/20.

The complaint was not substantiated and no deficiencies were cited. The facility was found in compliance with infection control regulations and has implemented recommended practices by CMS and CDC to prepare for COVID-19.

Complaint Investigation (CI# MS16752) was conducted and found not substantiated.

The State Agency conducted a COVID-19 Focused Infection Control Survey along with a Complaint Investigation (CI# MS16752) on 9/14/20.

The complaint was not substantiated and no deficiencies were cited. The facility was found in compliance with infection control regulations and has implemented recommended practices by CMS and CDC to prepare for COVID-19.

Complaint Investigation (CI# MS16752) was conducted and found not substantiated.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 9/14/2020.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness requirements.

A Covid-19 Focused Infection Control Survey was conducted by the State Agency to assess compliance with infection control regulations and preparedness for COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and had implemented CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) on 6/30/2020.

The facility was found to be in compliance with 42 CFR §483.73 related to E-0024 (b)(6).

A COVID-19 Focused Infection Control Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from April 20, 2020 through April 23, 2020 to assess compliance with infection control regulations related to COVID-19.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and has implemented the CMS and CDC recommended practices to prepare for COVID-19.

A COVID-19 Focused Emergency Preparedness Survey was conducted by the Centers for Medicare & Medicaid Services (CMS) from April 20, 2020 through April 23, 2020.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness for COVID-19.

The State Agency conducted an abbreviated/partial extended survey investigating complaint MS CI 16602 related to quality of care and treatment.

The concerns identified in the complaint were not substantiated, and no deficiencies were cited during the survey.

Complaint concerns related to quality of care and treatment were investigated and found not substantiated.

The State Agency conducted an abbreviated/partial extended survey investigating complaint MS CI 16602 related to quality of care and treatment.

The concerns identified in the complaint were not substantiated, no deficiencies were cited, and the facility was determined to be in substantial compliance with Medicare and Medicaid requirements.

Complaint concerns related to quality of care and treatment were investigated and found not substantiated.

The State Agency conducted a complaint survey and a revisit to the annual survey to determine compliance with Medicare and Medicaid requirements.

The State Agency substantiated allegations of Misappropriation of Property but found no deficiencies and determined the facility was in compliance with participation requirements.

The complaint investigation was related to allegations of Misappropriation of Property which were substantiated, but no deficiencies were cited.

The State Agency conducted a complaint survey and a revisit to the annual survey to determine compliance with Medicare and Medicaid requirements.

The agency substantiated allegations of Misappropriation of Property but cited no deficiencies. The facility was found in compliance with participation requirements.

The complaint investigation was related to allegations of Misappropriation of Property which were substantiated, but no deficiencies were cited.

The State Agency conducted an annual survey from 8/26/19 through 8/29/19 to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with Medicare and Medicaid requirements, with cited deficiencies related to transfer/discharge notice, care plan implementation, incontinent care, PEG tube site care, psychotropic medication management, and honoring resident food preferences.

The State Agency conducted a licensure survey from 8/26/19 to 8/29/19 to determine compliance with the Minimum Standards for The Institutions For The Aged And Infirm.

The facility was found not in compliance with state statutes related to urinary incontinence care, gastric feeding care, and food preparation. Deficiencies included improper incontinent care leading to potential cross contamination, inadequate PEG tube site care, and failure to honor resident food preferences.

The State Survey Agency conducted a complaint investigation (CI MS#16181) on 08/29/19 regarding Quality of Care/Treatment.

The complaint investigation was unsubstantiated with no deficiencies cited.

Complaint investigation CI MS#16181 was unsubstantiated for Quality of Care/Treatment with no deficiencies cited.

The State Survey Agency conducted a complaint investigation (CI MS#16181) on 08/29/19 regarding Quality of Care/Treatment.

The complaint investigation was unsubstantiated with no deficiencies cited.

Complaint investigation CI MS#16181 was unsubstantiated for Quality of Care/Treatment with no deficiencies cited.

A complaint investigation was conducted on February 12, 2019 at Briar Hill Rest Home.

The investigation was unsubstantiated with no deficiencies cited.

Complaint investigation was unsubstantiated with no deficiencies cited.

The State Agency conducted a complaint survey beginning 12/19/18, paused due to quarantine, resumed 1/2/19, and completed 1/3/19. Two complaints were investigated: one substantiated for failure to use a lift resulting in a hip fracture, and one not substantiated for failure to admit a resident.

The facility failed to implement the care plan requiring use of a mechanical lift with two-person assist for Resident #1, resulting in a fall and right hip fracture requiring hospitalization. CNA #1 transferred the resident alone without a lift, violating policy and care plan, leading to termination. The facility was found non-compliant with Medicare and Medicaid participation requirements.

Two complaints investigated: MS #15512 substantiated for accidents related to failure to use lift for Resident #1 causing hip fracture on 10/21/18; MS #15501 not substantiated for failure to admit Resident #4.

The State Agency conducted a complaint survey beginning 12/19/18, paused due to quarantine, resumed on 1/2/19, and completed on 1/3/19. Two complaints were investigated: one substantiated for failure to use a lift as care planned resulting in a hip fracture, and one not substantiated regarding failure to admit a resident.

The facility failed to prevent accidents for Resident #1 by not using two-person assistance and a mechanical lift as care planned, resulting in a hip fracture requiring hospitalization. The CNA responsible was terminated for non-compliance with policy. The facility implemented multiple in-service education programs and audits to prevent recurrence.

Two complaints were investigated: MS #15512 was substantiated for accidents/supervision related to failure to use a lift for Resident #1 resulting in a hip fracture on 10/21/18. MS #15501 was not substantiated for failure to admit Resident #4.

A complaint investigation was conducted at Briar Hill Rest Home on September 18, 2018.

The investigation was unsubstantiated with no deficiencies cited.

The complaint investigation was unsubstantiated with no deficiencies cited.

A complaint investigation was conducted at Briar Hill Rest Home on March 15, 2018.

The investigation was unsubstantiated with no deficiencies cited.

The complaint investigation was unsubstantiated with no deficiencies cited.

A complaint investigation was conducted on February 9, 2018 in the facility.

The investigation was unsubstantiated with no deficiencies cited.

Complaint investigation CMS #14948 was unsubstantiated with no deficiencies cited.

The State Survey Agency conducted an annual recertification survey to determine compliance with Medicare and Medicaid participation requirements.

The facility was found not in compliance with multiple regulatory requirements including resident self-determination, care plan revisions, medication administration timing, pharmacy services, dietary support personnel, menu adequacy, and life safety code violations related to exit egress.

The State Agency conducted a licensure survey at the facility from 01/08/2018 to 01/12/2018 to determine compliance with State Licensure Regulations for the Aged or Infirm.

The facility was found not in compliance with regulations related to residents' rights, safe food handling procedures, and meal and nutrition services. Specific deficiencies included failure to honor resident food preferences, improper calibration and use of food thermometers, lack of proper sanitizer concentration monitoring, and failure to adjust menus according to individual resident needs.