Inspection Reports for Briarcliff Health & Rehabilitation Center
5024 WESTERN AVENUE, SOUTH BEND, IN, 46619
Back to Facility ProfileInspection Report Summary
The most recent inspection on May 14, 2025, was a complaint investigation and found no deficiencies related to the allegations. Earlier inspections showed a pattern of deficiencies primarily involving emergency preparedness and life safety code compliance, as well as issues with resident care planning, medication management, food safety, and infection control. Complaint investigations were mostly unsubstantiated, though some substantiated complaints involved failure to protect residents’ rights and proper documentation, with corrective actions taken. No fines, immediate jeopardy findings, or license actions were listed in the available reports. The facility’s recent inspections indicate improvement in emergency preparedness and life safety compliance compared to prior surveys.
Deficiencies (last 4 years)
Deficiencies (over 4 years)
15.8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
276% worse than Indiana average
Indiana average: 4.2 deficiencies/yearDeficiencies per year
16
12
8
4
0
Census
Latest occupancy rate
100% occupied
Based on a May 2025 inspection.
This facility has shown a steady increase in demand based on occupancy rates.
Occupancy over time
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: Aug 8, 2025
Visit Reason
The inspection was conducted due to complaints regarding failure to report an unusual occurrence resulting in resident injuries, failure to provide necessary behavioral health care and services, and failure to store food in a sanitary manner.
Complaint Details
The complaint investigation focused on the facility's failure to report an unusual occurrence involving a resident who inserted objects into his rectum causing injury and hospitalization, failure to provide adequate behavioral health interventions for the resident, and failure to maintain food safety standards in labeling and storing food.
Findings
The facility failed to report an incident involving a resident inserting objects into his rectum that resulted in hospitalization, failed to implement effective behavioral interventions for the resident with a history of such behaviors, and failed to properly label and date leftover food in the kitchen and memory care kitchenette, posing potential risks to residents.
Deficiencies (3)
Failed to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities related to a resident inserting objects into his rectum causing injury and hospitalization.
Failed to ensure each resident received necessary behavioral health care and services, resulting in hospitalization due to behaviors for a resident with a history of inserting foreign objects into his rectum.
Failed to store food in a sanitary manner related to labeling and dating leftovers and throwing away expired food in the refrigerator for the kitchen and memory care kitchenette.
Report Facts
Residents affected: 1
Residents affected: 93
Total residents consuming food: 95
Deficiency counts: 3
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Executive Director | Executive Director (ED) | Named in relation to failure to report incident and involvement in interdisciplinary team discussions |
| Director of Nursing | Director of Nursing (DON) | Named in relation to behavioral health deficiency and notification of incident |
| Regional Nurse Consultant | Regional Nurse Consultant (RNC) | Provided information on care plan and resident behavior |
| Psychiatric Mental Health Nurse Practitioner | Psychiatric Mental Health Nurse Practitioner (PMHNP) | Provided information on resident's understanding of behavior consequences |
| Registered Nurse 6 | Registered Nurse (RN) | Assigned nurse during incident, unaware of resident's history |
| CNA 7 | Certified Nursing Assistant (CNA) | Assigned CNA during incident, unaware of resident's history |
| Director of Dietary | Director of Dietary (DD) | Interviewed regarding food labeling and storage deficiencies |
Inspection Report
Complaint Investigation
Census: 97
Capacity: 97
Deficiencies: 0
Date: May 14, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00458585.
Complaint Details
Complaint IN00458585 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00458585 were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census SNF/NF: 97
Census Payor Type - Medicare: 7
Census Payor Type - Medicaid: 82
Census Payor Type - Other: 8
Inspection Report
Complaint Investigation
Census: 94
Capacity: 94
Deficiencies: 0
Date: Mar 3, 2025
Visit Reason
This visit was conducted for the investigation of Complaint IN00453322.
Complaint Details
Complaint IN00453322 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in Complaint IN00453322 were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare residents: 2
Medicaid residents: 85
Other payor residents: 7
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Date: Oct 17, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00440812.
Complaint Details
Complaint IN00440812 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Census: 88
Total Capacity: 88
Medicaid Census: 71
Other Payor Census: 17
Medicare Census: 0
Inspection Report
Follow-Up
Census: 87
Capacity: 131
Deficiencies: 0
Date: Oct 11, 2024
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey to verify compliance following the initial surveys conducted on 09/06/24.
Findings
At this Post Survey Revisit, Briarcliff Health and Rehabilitation Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered with a fire alarm system and smoke detection, and no deficiencies were cited.
Report Facts
Certified beds: 131
Census: 87
Inspection Report
Life Safety
Census: 89
Capacity: 131
Deficiencies: 6
Date: Sep 6, 2024
Visit Reason
An Emergency Preparedness Survey and Life Safety Code Recertification and State Licensure Survey were conducted by the Indiana Department of Health in accordance with 42 CFR 483.73 and 42 CFR 483.90(a) respectively, to assess compliance with emergency preparedness and life safety requirements.
Findings
The facility was found not in compliance with emergency preparedness requirements, including failure to perform the required 3-year, 4-hour emergency generator exercise, and life safety code violations such as unsecured electrical panels, improper hazardous area door latching, improper use of power strips for high current devices, and lack of staff training on oxygen transfilling procedures.
Deficiencies (6)
Failed to implement emergency power system requirements; generator lacked required 3-year, 4-hour exercise.
Corridor door to laundry room (hazardous area) lacked latching hardware, leaving door unable to latch.
Electrical panel in 600-Hall unsecured due to unlocked wooden cabinet door; locking mechanism not functional.
Failed to maintain emergency power standby system testing documentation; 4-hour run test overdue.
Power strips used as substitute for fixed wiring to power high current draw equipment (microwave, coffee machine, refrigerators).
Staff not properly trained on oxygen transfilling procedures; no documentation or policy available.
Report Facts
Certified beds: 131
Census: 89
Deficiency count: 6
Date of generator exercise: Sep 12, 2024
Inspection Report
Renewal
Census: 89
Capacity: 89
Deficiencies: 8
Date: Aug 12, 2024
Visit Reason
This visit was for a Recertification and State Licensure Survey conducted from August 5 to August 12, 2024.
Findings
The facility was found deficient in multiple areas including care plan participation, fall prevention interventions, pain management, pharmacy services, food safety, infection control, linen handling, and environmental sanitation.
Deficiencies (8)
Failed to include resident or representative in care plan meetings for 1 of 3 residents reviewed.
Failed to implement fall prevention interventions related to signage and adaptive call light system for 1 of 20 residents reviewed for falls.
Failed to administer pain medication prior to dressing change resulting in severe pain for 1 of 1 residents observed for wound care.
Failed to maintain a system for reconciliation of controlled substances for 1 of 3 medication carts reviewed.
Failed to ensure pharmacy recommendations were reviewed and addressed timely by a physician for 2 of 5 residents reviewed for medications.
Failed to store and prepare food in a sanitary manner in 1 of 1 kitchens, including undated food items, wet food processor bowls, dusty ductwork and ceiling, and damaged pans.
Failed to ensure laundry staff transported residents' clothing appropriately, with clothing partially uncovered on carts.
Failed to maintain a sanitary environment related to clean air vents and dirty ceiling tiles on the 500 Hall.
Report Facts
Survey dates: 6
Residents reviewed for care planning: 3
Residents reviewed for falls: 20
Residents observed for wound care: 1
Medication carts reviewed: 3
Residents reviewed for medications: 5
Residents affected by food safety: 88
Laundry staff observed: 2
Air vents observed: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher A Gill | Administrator | Signed the report on 08/28/2024 |
| Regional Nurse | Provided policies and interviews related to falls, pain management, medication regimen review, and linen handling | |
| Director of Nursing | DON | Provided policies, interviews, and explanations related to care planning, pain management, and pharmacy recommendations |
| Social Services Director | Interviewed regarding care plan meeting documentation | |
| Unit Manager | Interviewed regarding fall prevention and pain medication administration | |
| ADON | Assistant Director of Nursing | Observed wound care and interviewed about pain medication |
| Laundry Aide 4 | Observed transporting residents' clothing uncovered | |
| Laundry Aide 5 | Observed transporting residents' clothing uncovered and interviewed about proper coverage | |
| Dietary Manager | DM | Observed kitchen sanitation issues and interviewed about food safety |
| Director of Maintenance | DM | Interviewed about cleaning responsibility for vents and ceiling tiles |
Inspection Report
Renewal
Deficiencies: 0
Date: Aug 12, 2024
Visit Reason
The inspection was conducted as a Paper Compliance Review related to the Recertification and Licensure Survey.
Findings
Briarcliff Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 during the Paper Compliance Review.
Inspection Report
Annual Inspection
Deficiencies: 8
Date: Aug 12, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to care planning, fall prevention, pain management, pharmaceutical services, food safety, infection control, and environmental safety at Briarcliff Health & Rehabilitation Center.
Findings
The facility was found deficient in multiple areas including failure to include residents in care plan meetings, inadequate fall prevention interventions, failure to administer pain medication prior to wound care, lack of reconciliation of controlled substances, delayed physician response to pharmacy recommendations, unsanitary food storage and preparation, improper transport of residents' clothing, and unclean air vents and ceiling tiles.
Deficiencies (8)
Failed to include the resident or representative in care plan meetings for 1 of 3 residents reviewed.
Failed to implement fall prevention interventions related to signage and adaptive call light system for a resident with repetitive falls.
Failed to administer pain medication as needed prior to a dressing change, resulting in severe pain during treatment.
Failed to maintain a system for reconciliation of controlled substances for 1 of 3 medication carts reviewed.
Failed to ensure pharmacy recommendations were reviewed and addressed timely by a physician for 2 of 5 residents reviewed for medications.
Failed to store and prepare food in a sanitary manner in the kitchen, including undated food items, wet food processor bowls, dusty ductwork and ceiling, and damaged pans.
Failed to ensure laundry staff transported residents' clothing appropriately, with clothing partially uncovered on carts.
Failed to maintain a sanitary environment related to clean air vents and dirty ceiling tiles on the 500 Hall, with dust and condensation droplets falling onto food carts.
Report Facts
Residents reviewed for care planning: 3
Residents reviewed for falls: 20
Residents observed for wound care: 1
Medication carts reviewed: 3
Residents reviewed for medications: 5
Residents affected by food safety issue: 88
Residents affected by infection control issue: 2
Vents with dust and condensation: 5
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Social Services Director | Indicated meeting with Resident 17 was not documented. | |
| Director of Nursing | Director of Nursing | Provided policy on Comprehensive Care Plans and commented on pain management. |
| ADON | Observed wound care and admitted resident was not given pain medication prior to dressing change. | |
| Unit Manager | Provided information on medication administration and fall prevention policies. | |
| Regional Nurse | Provided policies and information on fall prevention and medication regimen review. | |
| Qualified Medication Aide 6 | Indicated controlled substances should be counted and signed by two staff members. | |
| Director of Nursing (DON) | Director of Nursing | Discussed timeliness of physician responses to pharmacy recommendations. |
| Director of Maintenance | Indicated responsibility for cleaning vents and ceiling tiles. | |
| Dietary Manager | Acknowledged food safety deficiencies in kitchen. | |
| Laundry Aide 4 | Observed transporting residents' clothing partially uncovered. | |
| Laundry Aide 5 | Observed transporting residents' clothing partially uncovered and acknowledged it should be covered more. | |
| Housekeeping/Laundry Director | Indicated draw sheet was used to cover laundry carts but did not cover entire rack. |
Inspection Report
Complaint Investigation
Census: 87
Capacity: 87
Deficiencies: 0
Date: Jul 25, 2024
Visit Reason
This visit was conducted to investigate complaints IN00437868, IN00437784, IN00437006, and IN00436129 at Briarcliff Health & Rehabilitation Center.
Complaint Details
Complaints IN00437868, IN00437784, IN00437006, and IN00436129 were investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the allegations in any of the four complaints were cited. The facility was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2-3.1.
Report Facts
Census Bed Type: 87
Census Payor Type - Medicaid: 74
Census Payor Type - Other: 13
Inspection Report
Complaint Investigation
Census: 88
Capacity: 88
Deficiencies: 0
Date: Apr 9, 2024
Visit Reason
This visit was conducted for the investigation of Complaint IN00427588.
Complaint Details
Complaint IN00427588 was investigated and found to have no deficiencies related to the allegations.
Findings
No deficiencies related to the complaint allegations were cited. The facility was found to be in compliance with applicable regulations.
Report Facts
Medicare census: 5
Medicaid census: 69
Other payor census: 14
Inspection Report
Re-Inspection
Census: 86
Capacity: 86
Deficiencies: 0
Date: Jan 3, 2024
Visit Reason
This visit was a Post Survey Revisit (PSR) to the Investigation of Complaint IN00421297 completed on 2023-11-29.
Complaint Details
Complaint IN00421297 - Corrected.
Findings
Briarcliff Health & Rehabilitation Center was found to be in compliance with 42 CFR Part 483 Subpart B and 410 IAC 16.2-3.1 in regard to the PSR to the Investigation of Complaint IN00421297.
Report Facts
Census SNF/NF: 86
Census Medicare: 3
Census Medicaid: 67
Census Other: 16
Inspection Report
Complaint Investigation
Census: 85
Capacity: 85
Deficiencies: 1
Date: Nov 29, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00421391, IN00421297, IN00421061, and IN00420838 at Briarcliff Health & Rehabilitation Center.
Complaint Details
Complaint IN00421391 - No deficiencies related to the allegations are cited. Complaint IN00421297 - Federal/State deficiencies related to the allegations are cited at F600. Complaint IN00421061 - No deficiencies related to the allegations are cited. Complaint IN00420838 - No deficiencies related to the allegations are cited.
Findings
The facility was found deficient for failing to ensure a cognitively impaired resident was not videoed with derogatory captions on social media, which had the potential for negative psychosocial outcomes. The facility took corrective actions including staff education and disciplinary measures.
Deficiencies (1)
Facility failed to ensure a cognitively impaired resident was not videoed with derogatory captions on social media, violating freedom from abuse and neglect regulations.
Report Facts
Census: 85
Total Capacity: 85
Survey Dates: November 27, 28, and 29, 2023
Deficiency Completion Date: 12/28/2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Identified as the employee who posted the derogatory video of Resident E on social media. | |
| CNA 4 | Identified as related to CNA 3 and observed the video; involved in investigation. | |
| Administrator | Administrator | Conducted investigation and communicated with CNA 3 regarding the video. |
| Director of Nursing | Director of Nursing (DON) | Interviewed and reviewed video; involved in investigation and policy enforcement. |
| Nurse Manager | Nurse Manager | Observed the video and described its content during the investigation. |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Nov 29, 2023
Visit Reason
The inspection was conducted in response to a complaint regarding a cognitively impaired resident being videoed with derogatory captions on a social media network by a staff member.
Complaint Details
This Federal tag relates to complaint IN00421297. The complaint involved a video posted by CNA 3 showing Resident E with derogatory captions and taunting language, violating facility policies on abuse and social media use.
Findings
The facility failed to protect a resident from humiliation related to a video posted on social media by a CNA, which included derogatory captions and taunting. The video showed the resident lying shirtless in bed and included inappropriate language and emojis. The staff member responsible was suspended and likely terminated after acknowledging the video.
Deficiencies (1)
Facility failed to ensure a cognitively impaired resident was not videoed with derogatory captions on social media, resulting in potential negative psychosocial outcomes.
Report Facts
Facility self-report incident number: 444
Date of incident: Nov 4, 2023
Date of survey completion: Nov 29, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| CNA 3 | Certified Nursing Assistant | Originator of the video posted on social media |
| CNA 4 | Certified Nursing Assistant | Identified CNA 3 as originator of the video |
| Administrator | Spoke to CNA 3 regarding the video and informed her of suspension | |
| Director of Nursing | Director of Nursing (DON) | Spoke to CNA 4 and provided policy information |
| Nurse Manager | Nurse Manager | Observed the video and described its content |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 2, 2023
Visit Reason
Paper compliance review to the investigation of Complaint IN00416078 completed on 9/1/23.
Complaint Details
Complaint IN00416078 was investigated and found to be in compliance.
Findings
Briarcliff Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the complaint investigation.
Inspection Report
Follow-Up
Census: 77
Capacity: 131
Deficiencies: 0
Date: Sep 8, 2023
Visit Reason
A Post Survey Revisit (PSR) was conducted for the Emergency Preparedness Survey and the Life Safety Code Recertification and State Licensure Survey originally conducted on 07/31/23.
Findings
At this Post Survey Revisit, Briarcliff Health and Rehabilitation Center was found in compliance with Emergency Preparedness Requirements and Life Safety Code requirements. The facility was fully sprinklered with a fire alarm system and smoke detection, and remodeling was ongoing in unoccupied halls.
Report Facts
Certified beds: 131
Census: 77
Inspection Report
Complaint Investigation
Census: 81
Capacity: 81
Deficiencies: 1
Date: Sep 1, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00413753 and IN00416078. Complaint IN00413753 had no deficiencies related to the allegations, while Complaint IN00416078 resulted in federal/state deficiencies cited at F561.
Complaint Details
Complaint IN00416078 was substantiated with federal/state deficiencies cited at F561 related to failure to ensure resident self-determination and proper consent for ADL care. Complaint IN00413753 had no deficiencies related to the allegations.
Findings
The facility failed to facilitate resident self-determination by allowing a resident (Resident C) to be showered by a person who was not an employee and who did not have permission from the resident or the resident's responsible party. Resident C was severely cognitively impaired and dependent on assistance for personal hygiene. The facility lacked proper consent documentation for the outside caregiver providing ADL care.
Deficiencies (1)
Facility failed to facilitate resident self-determination through resident choice by allowing a non-employee to shower Resident C without permission from the resident or responsible party.
Report Facts
Census: 81
Total Capacity: 81
Survey Dates: August 31 and September 1, 2023
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher A Gill | Administrator | Interviewed regarding the complaint and investigation |
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: Sep 1, 2023
Visit Reason
The inspection was conducted in response to a complaint alleging that a distant relative had been showering Resident C without permission from the resident or the resident's responsible party.
Complaint Details
This Federal tag relates to complaint IN00416078. The complaint involved unauthorized showering of Resident C by a distant relative without permission from the resident's POA or family.
Findings
The facility failed to facilitate resident self-determination by allowing a non-employee, unauthorized person to shower Resident C without permission from the resident or power of attorney. Interviews confirmed the distant relative had been showering the resident for several months without documented consent.
Deficiencies (1)
Facility failed to promote and facilitate resident self-determination through support of resident choice by allowing a non-employee to shower Resident C without permission.
Employees mentioned
| Name | Title | Context |
|---|---|---|
| RN 2 | Registered Nurse | Mentioned as the nurse who reported an unknown family member had been showering Resident C for about 4 months. |
| CNA 1 | Certified Nursing Assistant | Reported seeing a person she thought was a family member shower Resident C at least twice. |
| Director of Nursing | Provided the facility policy on Activities of Daily Living supporting resident care with consent. |
Inspection Report
Routine
Census: 75
Capacity: 131
Deficiencies: 13
Date: Jul 31, 2023
Visit Reason
Routine Emergency Preparedness, Life Safety Code Recertification, and State Licensure Survey conducted by the Indiana Department of Health.
Findings
The facility was found not in compliance with Emergency Preparedness requirements, Life Safety Code, and other regulatory standards including generator inspections, fire door maintenance, sprinkler system inspections, exit signage, corridor door functionality, and evacuation plan completeness.
Deficiencies (13)
Failed to implement emergency power system weekly inspections as required by NFPA 110 and Life Safety Code.
Egress doors were locked with padlocks requiring keys, delaying evacuation.
Stairwell exit door did not latch properly.
Exit sign above 200-Hall exit door was not illuminated.
Fire alarm system visual inspections were not documented semi-annually and annual inspection was overdue.
Sprinkler system quarterly inspection documentation missing for first quarter 2023; internal pipe inspection documentation unavailable.
Missing ceiling tiles in two unoccupied wings could delay sprinkler activation.
Office door held open with wedge, preventing proper closing and latching.
25 of 26 corridor doors in unoccupied wings lacked proper latching hardware or were missing doors.
Fire dampers inspection documentation missing; inspections completed in August 2023.
Fire door assemblies lacked annual inspection documentation.
Weekly generator inspection documentation missing for 2 of 52 weeks.
Evacuation and relocation plan did not include locations of smoke/fire barriers.
Report Facts
Certified beds: 131
Current census: 75
Missing weekly generator inspections: 2
Missing sprinkler quarterly inspection: 1
Fire door assemblies: 5
Corridor doors non-compliant: 25
Ceiling tiles missing: 200
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher A Gill | Administrator | Signed report |
| Maintenance Supervisor | Interviewed regarding generator inspections, fire alarm, sprinkler system, fire doors, corridor doors, and other deficiencies | |
| Regional Facilities Director | Interviewed and acknowledged deficiencies during exit conference | |
| Business Office Manager | Interviewed regarding key access to courtyard gates |
Inspection Report
Annual Inspection
Census: 76
Capacity: 76
Deficiencies: 6
Date: Jul 14, 2023
Visit Reason
This visit was for a Recertification and State Licensure Survey, which included the Investigation of three complaints (IN00401518, IN00400894, and IN00412250).
Complaint Details
Three complaints (IN00401518, IN00400894, IN00412250) were investigated with no deficiencies related to the allegations cited.
Findings
The facility was found deficient in multiple areas including care plan revisions, ADL care for dependent residents, treatment and devices to maintain hearing/vision, tube feeding management, medication storage, and food procurement and sanitation. No deficiencies were cited related to the complaints investigated.
Deficiencies (6)
Failed to revise/update a resident care plan when a wander guard was discontinued for 1 of 21 residents reviewed (Resident 46).
Failed to ensure showers and/or nail care was provided for 2 of 5 residents reviewed for ADL needs (Residents 44 and 48).
Failed to ensure 2 of 2 residents reviewed for hearing needs received timely treatment and recommended hearing devices (Residents 60 and 29).
Failed to elevate the head of bed during enteral feeding and label feeding bags appropriately for 1 of 1 resident reviewed for tube feeding (Resident 48).
Failed to ensure medications were labeled and stored appropriately in 1 of 2 medication rooms and 1 of 3 medication carts.
Failed to maintain clean exhaust ductwork and hoods in the kitchen and above food preparation area, posing a potential risk to 74 of 76 residents.
Report Facts
Census Bed Type: 76
Census Payor Type: 58
Census Payor Type: 18
Deficiencies cited: 6
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Christopher A Gill | Administrator | Signed the report |
| RN 14 | Registered Nurse | Interviewed regarding Resident 44's nail care |
| LPN 19 | Licensed Practical Nurse | Interviewed regarding enteral feeding head of bed elevation |
| LPN 4 | Licensed Practical Nurse | Interviewed regarding medication refrigerator use |
| LPN 22 | Licensed Practical Nurse | Interviewed regarding medication labeling and pharmacy practices |
| Director of Nursing | Provided policies and interviewed about care plan revisions, ADL care, enteral feeding, and medication storage | |
| Regional Nurse | Provided policies on care plan revisions, nail care, and enteral feeding | |
| Social Services Director | Interviewed regarding hearing aid procurement and follow-up | |
| Certified Nurse Aide 15 | CNA | Interviewed regarding showering and nail care |
| Certified Nurse Aide 16 | CNA | Interviewed regarding showering and hygiene care |
| Certified Nurse Aide 18 | CNA | Interviewed regarding showering and hygiene care |
| Employee 10 | Interviewed regarding audiology services and hearing aid orders | |
| Employee 11 | Interviewed regarding kitchen ductwork cleaning responsibility | |
| Employee 12 | Interviewed regarding kitchen ductwork cleaning frequency | |
| Employee 13 | Interviewed regarding kitchen ductwork cleaning schedule |
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Jul 14, 2023
Visit Reason
Paper Compliance Review to the Recertification and Licensure survey completed on 7/14/2023.
Findings
Briarcliff Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Recertification and Licensure Survey.
Inspection Report
Annual Inspection
Deficiencies: 6
Date: Jul 14, 2023
Visit Reason
The inspection was conducted as part of the annual survey to assess compliance with regulatory requirements for nursing home care, including care planning, activities of daily living assistance, hearing and vision services, feeding tube care, medication storage and labeling, and food safety.
Findings
The facility was found deficient in multiple areas including failure to update a resident's care plan after discontinuation of a wander guard, inadequate provision of showering and nail care for residents, failure to ensure timely hearing aid provision and communication support, improper feeding tube care including failure to elevate head of bed and label feeding bags, medication storage and labeling deficiencies, and failure to maintain clean kitchen exhaust ductwork and hoods.
Deficiencies (6)
Failed to revise/update a resident care plan when a wander guard was discontinued for 1 of 21 residents reviewed.
Failed to ensure showers and/or nail care was provided for 2 of 5 residents reviewed for Activities of Daily Living needs.
Failed to ensure 2 of 2 residents reviewed for hearing needs received timely treatment and recommended hearing devices.
Failed to elevate the head of bed when an enteral feeding pump was infusing, and label feeding bags appropriately for 1 of 1 resident reviewed for tube feeding.
Failed to ensure medications were labeled and stored appropriately in 1 of 2 medication rooms and 1 of 3 medication carts observed.
Failed to maintain clean exhaust ductwork and hoods in the kitchen and above food preparation area, potentially affecting 74 of 76 residents.
Report Facts
Residents reviewed for care plan update: 21
Residents reviewed for ADL needs: 5
Residents affected by ADL deficiency: 2
Residents reviewed for hearing needs: 2
Residents affected by hearing deficiency: 2
Resident reviewed for feeding tube care: 1
Residents affected by medication storage deficiency: 1
Residents potentially affected by kitchen ductwork deficiency: 74
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan update process and feeding tube care expectations | |
| Regional Nurse | Provided policies on care plan revisions and feeding tube feeding | |
| RN 14 | Registered Nurse | Interviewed regarding nail care for Resident 44 |
| Certified Nurse Aide 15 | CNA | Interviewed about showering procedures |
| Certified Nurse Aide 16 | CNA | Interviewed about showering procedures |
| Certified Nurse Aide 18 | CNA | Interviewed about showering procedures |
| Social Services Director | Interviewed regarding hearing aid delays and resident communication needs | |
| Licensed Practical Nurse 19 | LPN | Interviewed regarding feeding tube care and head of bed elevation |
| Licensed Practical Nurse 4 | LPN | Interviewed regarding medication storage practices |
| Licensed Practical Nurse 22 | LPN (agency nurse) | Interviewed regarding medication labeling and pharmacy practices |
| Employee 11 | Interviewed regarding cleaning responsibilities for kitchen ductwork | |
| Employee 12 | Interviewed regarding cleaning schedule for kitchen ductwork | |
| Employee 13 | Interviewed regarding cleaning schedule and procedures for kitchen ductwork |
Inspection Report
Complaint Investigation
Census: 83
Capacity: 83
Deficiencies: 0
Date: Jan 4, 2023
Visit Reason
This visit was conducted for the investigation of complaints IN00397253 and IN00395652.
Complaint Details
Complaint IN00397253 - Substantiated with no deficiencies cited. Complaint IN00395652 - Unsubstantiated due to lack of evidence.
Findings
Complaint IN00397253 was substantiated but no deficiencies related to the allegations were cited. Complaint IN00395652 was unsubstantiated due to lack of evidence. The facility was found to be in compliance with relevant regulations.
Report Facts
Census Bed Type: 83
Census Payor Type - Medicare: 1
Census Payor Type - Medicaid: 64
Census Payor Type - Other: 18
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Jan 3, 2023
Visit Reason
The inspection was conducted as a paper compliance review related to the investigation of complaints IN00388905 and IN00391843 completed on October 20, 2022.
Complaint Details
The visit was complaint-related, reviewing compliance with complaints IN00388905 and IN00391843. The facility was found to be in compliance.
Findings
Briarcliff Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 regarding the paper compliance review of the complaint investigation.
Inspection Report
Re-Inspection
Census: 81
Capacity: 111
Deficiencies: 0
Date: Nov 1, 2022
Visit Reason
A 2nd Post Survey Revisit (PSR) was conducted following the 1st PSR survey on 09/19/22 for the Preoccupancy survey conducted on 08/03/22 related to a bed increase of 20 beds at Briarcliff Health & Rehabilitation Center.
Findings
At this Post Survey Revisit, the facility was found in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, Chapter 19, Existing Health Care Occupancies.
Report Facts
Bed increase: 20
Inspection Report
Complaint Investigation
Census: 78
Capacity: 78
Deficiencies: 2
Date: Oct 20, 2022
Visit Reason
This visit was for Investigation of Complaints IN00391843, IN00391222 and IN00388905, including a COVID-19 Focused Infection Control Survey.
Complaint Details
Complaint IN00391843 with a Covid-19 Focused Survey - Substantiated with deficiencies cited at F880. Complaint IN00391222 - Substantiated with no deficiencies cited. Complaint IN00388905 - Substantiated with deficiencies cited at F812.
Findings
The facility was found deficient in maintaining proper food temperatures for hot and cold items affecting all 78 residents, and failed to properly prevent and contain COVID-19 infections for 36 residents by not following PPE guidelines.
Deficiencies (2)
Failed to ensure hot food items and cold liquids were maintained out of potentially hazardous temperatures affecting all 78 residents.
Failed to establish and maintain an infection prevention and control program, including proper use of PPE, resulting in COVID-19 transmission risks for 36 residents.
Report Facts
Residents affected: 78
Residents affected: 36
Census: 78
Total capacity: 78
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Elizabeth Kegg | VP of Clinical | Signed report as provider/supplier representative |
Inspection Report
Complaint Investigation
Deficiencies: 0
Date: Oct 3, 2022
Visit Reason
Paper Compliance to the Investigation of Complaint IN00387135 completed on 8/17/2022.
Complaint Details
Investigation of Complaint IN00387135 completed on 8/17/2022; facility found in compliance.
Findings
Briarcliff Nursing and Rehabilitation was found to be in compliance with 42 CFR Part 483, Subpart B and 410 IAC 16.2 in regard to the Paper Compliance Review to the Complaint Investigation.
Inspection Report
Re-Inspection
Census: 91
Capacity: 111
Deficiencies: 2
Date: Sep 19, 2022
Visit Reason
A Post Survey Revisit was conducted for the Preoccupancy survey related to a bed increase of 20 beds conducted on 08/03/22 by the Indiana Department of Health in accordance with 42 CFR 483.90(a).
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and NFPA 101 Life Safety Code. Deficiencies included a corridor door in resident room 409 that did not latch properly, affecting 2 residents, and failure to provide privacy curtains in 9 of 20 resident rooms with at least 2 residents, potentially affecting at least 9 residents.
Deficiencies (2)
Corridor door to resident room 409 did not latch into the frame, failing to resist passage of smoke and lacking positive latching hardware.
Facility failed to provide privacy curtains in 9 of 20 resident sleeping rooms containing at least 2 residents.
Report Facts
Bed increase: 20
Facility capacity: 111
Census: 91
Resident rooms missing privacy curtains: 9
Residents potentially affected by door latch deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Interim Administrator | Interviewed regarding door latch deficiency and privacy curtain observations |
Inspection Report
Complaint Investigation
Census: 84
Capacity: 84
Deficiencies: 1
Date: Aug 16, 2022
Visit Reason
This visit was conducted for the investigation of complaints IN00387850 and IN00387135. Complaint IN00387850 was unsubstantiated, while complaint IN00387135 was substantiated with related deficiencies cited.
Complaint Details
Complaint IN00387850 was unsubstantiated and did not occur. Complaint IN00387135 was substantiated with federal/state deficiencies cited at F773 related to failure in lab result reporting.
Findings
The facility failed to ensure that results from physician-ordered lab work were completed with results in the resident's chart and reported to the physician, specifically for Resident D. The CMP lab results were missing due to a defective blood tube and lack of lab notification to the facility.
Deficiencies (1)
Failure to ensure results from physician ordered lab work were completed with results in the resident's chart and reported to the physician.
Report Facts
Census: 84
Total Capacity: 84
Medicare Census: 4
Medicaid Census: 67
Other Payor Census: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding lab result notification failure and corrective actions |
Inspection Report
Original Licensing
Census: 85
Capacity: 111
Deficiencies: 4
Date: Aug 3, 2022
Visit Reason
A Preoccupancy Survey was conducted for a bed increase of 20 T18/19 beds in multiple rooms at Briarcliff Health and Rehabilitation Center by the Indiana Department of Health in accordance with 42 CFR 483 Subpart B.
Findings
The facility was found not in compliance with Medicare/Medicaid participation requirements, Life Safety from Fire, and the 2012 NFPA 101 Life Safety Code. Deficiencies included failure to ensure hazardous area doors were self-closing and latched, corridor doors not closing properly, lack of privacy curtains in resident rooms, and insufficient nurse call light access in rooms increasing from one to two beds.
Deficiencies (4)
Failed to ensure the soiled utility room door on 500 hall was protected as a hazardous area with a self-closing door that automatically latches.
Corridor door to resident room 409 did not latch into the frame and was not closing properly.
Failed to provide privacy curtains in 11 of 20 resident sleeping rooms containing at least 2 residents.
Failed to provide access for nurse call lights in 11 of 20 resident sleeping rooms increasing from one bed to two beds.
Report Facts
Bed increase: 20
Census: 85
Total capacity: 111
Resident rooms lacking privacy curtains: 11
Residents potentially affected by lack of privacy curtains: 22
Resident rooms lacking nurse call light access: 11
Residents potentially affected by nurse call light deficiency: 11
Residents potentially affected by hazardous door deficiency: 12
Residents potentially affected by corridor door deficiency: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Maintenance Director | Interviewed regarding hazardous area door deficiencies and corrective actions | |
| Administrator | Interviewed regarding door deficiencies and corrective actions | |
| Admissions Admin | Interviewed regarding door deficiencies, privacy curtains, and nurse call light access |
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