Inspection Report
Renewal
Census: 28
Capacity: 55
Deficiencies: 5
Mar 18, 2025
Visit Reason
The inspection was conducted as a renewal licensing study to evaluate compliance with state regulations and to determine if the facility meets the requirements for license renewal.
Findings
The facility was found to be in non-compliance with multiple rules including tuberculosis screening documentation, improper storage of clean linens, incomplete dishwasher sanitization logs, unlabeled food items, and unsafe storage of hazardous materials. Violations were established for each of these findings.
Deficiencies (5)
| Description |
|---|
| One resident's tuberculosis screening record could not be located or found. |
| Clean linens were stored with items such as an ironing board, wheelchair foot pedals, resident personal laundry, and housekeeping cleaning items, posing a risk for cross contamination. |
| Dishwasher sanitization log for February 2-5, 2025 had incomplete and/or blank entries, making it unclear if dishware and utensils were properly sanitized. |
| Multiple food items were found unlabeled without appropriate open dates in various kitchenettes and activity room refrigerators and cabinets. |
| Hazardous and toxic chemicals along with sharp items were stored unsecured in unlocked drawers and cabinets accessible to residents, posing a risk of harm. |
Report Facts
Number of residents interviewed/observed: 28
Facility capacity: 55
Number of staff interviewed/observed: 9
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Carol Del Raso | Authorized Representative | Named as authorized representative of the facility |
| Judy Finnie | Administrator/Licensee Designee | Named as administrator/licensee designee of the facility |
| Julie Viviano | Licensing Staff | Author of the inspection report and correspondence |
Inspection Report
Complaint Investigation
Capacity: 55
Deficiencies: 1
Mar 12, 2025
Visit Reason
The investigation was initiated due to a complaint alleging that facility staff were not providing showers or assistance with eating in accordance with the service plan, and a separate allegation that Resident A was administered too much insulin causing hospitalization.
Findings
The investigation established a violation that the facility's service plan did not accurately reflect the level of care provided to Resident A, who required assistance with eating despite the plan stating independence. The allegation of insulin overdose was not substantiated as the facility took immediate corrective actions including notifying the physician and family, hospitalizing Resident A, and retraining staff.
Complaint Details
The complaint alleged that facility staff were not providing showers or assistance with eating as per the service plan, and that Resident A was administered too much insulin causing hospitalization. The first allegation was substantiated; the second was not.
Deficiencies (1)
| Description |
|---|
| The facility's service plan for Resident A inaccurately indicated independence with eating and dining tasks, while Resident A required assistance, constituting a violation. |
Report Facts
Capacity: 55
Complaint Receipt Date: Mar 12, 2025
Medication administration error date: Feb 18, 2025
Corrective action plan due days: 15
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Finnie | Administrator | Interviewed during investigation; provided statements about Resident A's care |
| Julie Viviano | Licensing Staff | Author of the Special Investigation Report |
Inspection Report
Renewal
Census: 18
Capacity: 55
Deficiencies: 0
Sep 21, 2023
Visit Reason
The inspection was conducted as a renewal inspection to determine compliance with applicable licensing statutes and rules for Briarwood Assisted Living.
Findings
The facility was found to be in substantial compliance with all applicable rules and statutes, and renewal of the license was recommended.
Report Facts
Number of staff interviewed and/or observed: 7
Number of residents interviewed and/or observed: 18
Capacity: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Finnie | Administrator/Licensee Designee | Named as Administrator/Licensee Designee of the facility |
Inspection Report
Complaint Investigation
Capacity: 55
Deficiencies: 1
Oct 27, 2022
Visit Reason
The inspection was conducted in response to a complaint alleging that residents do not have access to snacks because the kitchen and pantry are locked at 6:00pm.
Findings
The investigation found that residents are provided three meals and snacks, and care staff have access to the kitchen and pantry via a key on the medication cart. However, the facility failed to ensure an organized program to communicate the availability of the key to direct care staff, constituting a violation.
Complaint Details
The complaint alleged residents do not have access to snacks because the kitchen and pantry are locked at 6:00pm and care staff do not have access to food for medication passes. The violation regarding lack of access to snacks was not established, but an additional violation was found related to failure to maintain an organized program.
Deficiencies (1)
| Description |
|---|
| The facility did not ensure an organized program to provide room and board, protection, supervision, assistance, and supervised personal care for its residents related to access to kitchen and pantry keys. |
Report Facts
Capacity: 55
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Judy Finnie | Administrator | Interviewed regarding kitchen and pantry access and snack availability |
| Nikkie Cleveland | Chef | Interviewed regarding kitchen and pantry access and snack availability |
| Kimberly Horst | Licensing Staff | Conducted the investigation and authored the report |
| Carol DelRaso | Authorized Representative | Participated in exit conference |
Inspection Report
Renewal
Capacity: 55
Deficiencies: 0
Oct 3, 2022
Visit Reason
The visit was conducted as a renewal inspection to review licensing activity and compliance with public health codes and administrative rules regulating the home for the aged facility.
Findings
The facility was found to be in compliance with all applicable rules and statutes, and renewal of the license was recommended.
Report Facts
Capacity: 55
Inspection Report
Original Licensing
Capacity: 55
Deficiencies: 0
Jul 12, 2012
Visit Reason
The inspection was conducted as part of an original licensing study to review an application requesting an increase in bed capacity from 38 to 55 at Briarwood Assisted Living.
Findings
The on-site inspection of the new addition was completed and found to be in compliance with all homes for the aged licensing rules. Final approvals were granted by the Bureau of Fire Services and Health Facilities Engineering Section.
Report Facts
Licensed capacity increase: 17
Capacity: 55
Inspection date: Jul 12, 2012
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Linda Denniston | Licensing Staff | Conducted the inspection and authored the report |
| Betsy Montgomery | Area Manager | Approved the licensing capacity increase |
Inspection Report
Original Licensing
Capacity: 38
Deficiencies: 0
Jun 2, 2008
Visit Reason
The visit was conducted as an original licensing study to determine compliance with applicable licensing statutes and administrative rules for Briarwood Assisted Living.
Findings
The facility was found to be in substantial compliance with licensing requirements, resulting in the recommendation and issuance of a temporary license with a maximum capacity of 38 beds. The facility is newly constructed, home-like, and designed for residents over age 60 with various amenities and accessibility features.
Employees Mentioned
| Name | Title | Context |
|---|---|---|
| Vicki C. Davison | Licensing Staff | Author of the licensing study report and recommendation for temporary license issuance. |
| Betsy Montgomery | Area Manager | Approved the licensing study report and recommendation. |
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