Inspection Reports for
Briarcliff Health & Rehabilitation Center

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

Three complaints (IN00401518, IN00400894, IN00412250) were investigated with no deficiencies related to the allegations cited.

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.

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.

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.

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.

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.

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.

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.

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.