Inspection Report
Re-Inspection
Deficiencies: 0
Mar 20, 2025
Visit Reason
A revisit survey was conducted on March 20, 2025, for all previous deficiencies cited on the February 18, 2025, Life Safety Code survey.
Findings
All deficiencies have been corrected at this time. The facility is in compliance with all regulations surveyed.
Inspection Report
Life Safety
Census: 111
Capacity: 122
Deficiencies: 3
Feb 18, 2025
Visit Reason
The annual Federal Life Safety Code survey was conducted by the State Survey Agency on 02/18/2025 to assess compliance with the National Fire Protection Association 101 Life Safety Code, 2012 Edition, as referenced in 42 CFR 483.90.
Findings
Life Safety Code deficiencies were identified during the survey, indicating the facility is not in compliance with all regulations surveyed. Deficiencies relate to means of egress requirements, fire alarm system maintenance, and sprinkler system maintenance and testing.
Deficiencies (3)
| Description |
|---|
| Means of egress signage was deficient, with conflicting signage affixed to exit doors in stairwells #4 and #5, potentially impacting 42 residents and an indeterminable number of staff and visitors. |
| The fire alarm system was not maintained in accordance with National Fire Protection Association (NFPA) 101 Life Safety Code 2012 Edition and NFPA 72 National Fire Alarm and Signaling Code 2010 Edition, potentially impacting 111 residents and an indeterminable number of staff and visitors. |
| The sprinkler system was not maintained and tested in accordance with NFPA 25 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, potentially impacting 111 residents and an indeterminable number of staff and visitors. |
Report Facts
Capacity: 122
Census: 111
Deficiencies cited: 3
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Director of Maintenance | Director of Maintenance | Interviewed regarding fire alarm and sprinkler system maintenance and testing deficiencies |
| Maintenance Director | Maintenance Director | Present during life safety tour and acknowledged signage issues |
Inspection Report
Plan of Correction
Deficiencies: 0
Mar 14, 2024
Visit Reason
An off-site desk audit was conducted on March 14, 2024, to review all previous deficiencies cited on February 15 and 16, 2024, based on an acceptable plan of correction and supporting documentation.
Findings
All deficiencies previously cited have been corrected, and the facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Census: 110
Capacity: 122
Deficiencies: 2
Feb 16, 2024
Visit Reason
A Recertification Survey and complaint investigation survey was conducted at Briarcliffe Manor from 2024-01-12 through 2024-02-16 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities, State licensure, and emergency preparedness surveys.
Findings
The facility was found deficient in infection prevention and control related to failure to maintain an infection prevention and control program for a resident positive for MRSA. Additionally, a Life Safety Code deficiency was identified related to failure to maintain the Emergency Power Supply System generator in accordance with NFPA standards.
Complaint Details
The complaint investigation was substantiated with findings related to infection prevention and control deficiencies involving a resident with MRSA. The resident was not placed on appropriate isolation precautions upon admission, and staff failed to follow required infection control procedures.
Severity Breakdown
SS=D: 1
Deficiencies (2)
| Description | Severity |
|---|---|
| Failure to maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases and infections for a resident positive for Methicillin Resistant Staphylococcus Aureus (MRSA). | SS=D |
| Failure to ensure that the Emergency Power Supply System (EPSS) generator was maintained in accordance with National Fire Protection Association (NFPA) standards, impacting 110 residents and an indeterminable number of staff and visitors. | — |
Report Facts
Capacity: 122
Census: 110
Residents impacted: 110
Deficiency count: 1
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Licensed Practical Nurse | Observed performing wound care without required gown during dressing change for MRSA positive resident |
| Infection Preventionist | Unable to provide evidence that resident was placed on contact precautions for MRSA upon admission | |
| Maintenance Director | Unable to provide evidence of obtaining and documenting generator battery specific gravity readings for 12 months |
Inspection Report
Follow-Up
Deficiencies: 0
Feb 6, 2023
Visit Reason
A follow-up to a previous life safety survey was conducted to verify correction of prior deficiencies.
Findings
All previous deficiencies were corrected and no new deficiencies were identified. The facility is in compliance with all regulations surveyed.
Inspection Report
Complaint Investigation
Deficiencies: 5
Jan 6, 2023
Visit Reason
A Recertification Survey and complaint investigation survey were conducted at Briarcliffe Manor Nursing Home from 01/03/2023 through 01/06/2023 to determine compliance with 42 CFR Part 483 requirements for Long Term Care Facilities. A State licensure and emergency preparedness surveys were also conducted.
Findings
Deficiencies were cited related to failure to protect identifying information of residents, failure to maintain acceptable nutritional status for a resident, failure to ensure food safety and proper sanitation, and failure to maintain COVID-19 vaccination tracking documentation for staff. Life Safety Code deficiencies were also identified related to egress door locking mechanisms.
Complaint Details
The complaint investigation was conducted alongside the recertification survey. The survey included review of resident/staff roster listings, nutritional interventions, food safety practices, and COVID-19 vaccination documentation. The complaint was substantiated as deficiencies were cited.
Deficiencies (5)
| Description |
|---|
| Facility failed to protect identifying information for 9 residents listed in the survey results binder. |
| Facility failed to ensure residents maintain acceptable parameters of nutritional status for 1 of 9 residents reviewed. |
| Facility failed to ensure food is served and distributed in accordance with professional standards for food service safety, including proper sanitizing and temperature controls. |
| Facility failed to ensure all staff COVID-19 vaccination status was tracked and documented properly. |
| Life Safety Code deficiency: Egress doors lacked compliant door-locking arrangements and manual release mechanisms. |
Report Facts
Residents with identifying information not protected: 9
Residents reviewed for nutritional status: 9
Weight loss data points: 9
Dates of survey: 4
Residents potentially affected by fire safety deficiency: 17
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nursing Assistant | Interviewed regarding failure to administer gluten free milkshake to resident. |
| Staff B | Dietary Aide | Observed not wearing beard restraint while delivering meals and washing dishes. |
| Staff D | Dietary Aide | Observed not wearing beard restraint on breakfast serving line. |
| Staff E | Hospice Nurse Practitioner | Named in COVID-19 vaccination tracking deficiency. |
| Staff F | Hospice Music Therapist | Named in COVID-19 vaccination tracking deficiency. |
| Staff G | Hospice Spiritual Counselor | Named in COVID-19 vaccination tracking deficiency. |
| Staff H | Hospice Nursing Assistant | Named in COVID-19 vaccination tracking deficiency. |
| Staff I | Palliative Provider | Named in COVID-19 vaccination tracking deficiency. |
| Director of Nursing Services | Interviewed regarding protection of resident identifying information and COVID-19 vaccination tracking. | |
| Vice President of Operations | Interviewed regarding dishwasher repairs and food safety deficiencies. | |
| Food Service Director/Dietician | Responsible for weekly tray checks and audits related to nutritional interventions and food safety. | |
| Maintenance Director | Interviewed regarding life safety deficiencies related to egress door locking mechanisms. |
Inspection Report
Routine
Census: 88
Capacity: 122
Deficiencies: 0
Sep 9, 2021
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Center for Health Facilities and Regulation to assess compliance with infection control regulations.
Findings
The facility was found to be in compliance with 42 CFR §483.80 Infection Control regulations and has implemented CDC recommended practices to prepare for COVID-19.
Report Facts
Capacity: 122
Census: 88
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