Inspection Reports for Briarwood Health and Rehabilitation Center

A COVID-19 Focused Infection Control Survey in conjunction with an Abbreviated/Partial Extended Survey to investigate complaint #GA00215855 was conducted.

The facility was found to be in compliance with 42 CFR §483.80 infection control regulations and CMS/CDC recommended COVID-19 practices. The complaint was unsubstantiated and no regulatory violations were cited.

Complaint #GA00215855 was unsubstantiated and no regulatory violations were cited.

The inspection was conducted as a Licensure survey to assess compliance for facility licensure renewal.

No deficiencies were identified during the Licensure survey.

A standard survey was conducted at Briarwood Health & Rehabilitation from May 17, 2021 through May 20, 2021. In addition, Complaint Intake Number GA00213749 was investigated in conjunction with this standard survey.

The standard survey revealed that the facility was in substantial compliance with Medicare/Medicaid regulations. The complaint GA00213749 was found to be unsubstantiated.

Complaint GA00213749 was investigated and found to be unsubstantiated.

The visit was conducted to perform a Life Safety Code Survey to assess compliance with Medicare/Medicaid participation requirements and the NFPA 101 Life Safety Code 2012 edition.

The facility was found to be in substantial compliance with the emergency preparedness program requirements and Life Safety Code standards. Part of the facility was not surveyed due to patients under observation for COVID-19.

An abbreviated/partial extended survey was conducted to investigate complaints #GA00211662, #GA00211696, and #GA00212580.

The complaints investigated were unsubstantiated and no deficiencies were identified during the survey.

Complaints #GA00211662, #GA00211696, and #GA00212580 were investigated and found to be unsubstantiated with no deficiencies.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00210731.

The complaint was unsubstantiated and no regulatory violations were cited during the survey.

Complaint #GA00210731 was investigated and found to be unsubstantiated.

An abbreviated/partial extended survey was conducted to investigate complaint #GA00209743.

The complaint was unsubstantiated and no regulatory violations were cited during the survey.

Complaint #GA00209743 was investigated and found to be unsubstantiated.

An unannounced abbreviated/partial survey was conducted to investigate complaints #GA00209096 and GA00209325.

The complaints #GA00209096 and GA00209325 were unsubstantiated with no deficiencies cited.

Complaints #GA00209096 and GA00209325 were investigated and found to be unsubstantiated with no deficiencies cited.

A desk review was completed by the Fire Safety Supervisor to verify that all citations had been corrected in accordance with the approved plan of correction.

The review confirmed that all previously cited deficiencies had been corrected as per the approved plan of correction.

An abbreviated/partial extended survey was conducted to investigate multiple complaints against the facility.

The complaints investigated during the survey were unsubstantiated and no deficiencies were cited.

The survey investigated complaints GA00203392, GA00203435, GA00203580, GA00203742, GA00204640, GA00206038, and GA00206879, all of which were found to be unsubstantiated.

A follow-up to the licensure survey conducted on February 6, 2020, to verify correction of previous deficiencies.

The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of March 22, 2020.

A follow-up to the Recertification survey of February 6, 2020 was conducted to verify correction of previously identified deficiencies.

The follow-up survey revealed that all deficiencies were corrected and the facility was in substantial compliance as of March 22, 2020.

An investigation by desk review of complaint #GA00204868 was conducted from 6/8/2020 through 6/11/2020, followed by a COVID-19 Focused Infection Control Survey on June 23-24, 2020.

No abuse, neglect, or immediate jeopardy concerns were noted. The facility was found to be in compliance with infection control regulations and CMS/CDC recommended practices for COVID-19. No deficiencies were cited during the investigations.

Investigation of complaint #GA00204868 was conducted by desk review and later onsite activities were planned but not completed due to facility access restrictions. No substantiated abuse, neglect, or immediate jeopardy was found.

A COVID-19 Focused Emergency Preparedness and Infection Control Survey was conducted by Ascellon on behalf of the Georgia Department of Community Health on June 23-24, 2020.

The facility was found to be in compliance with 42 CFR §483.73 related to emergency preparedness and 42 CFR §483.80 related to infection control regulations, implementing CMS and CDC recommended practices to prepare for COVID-19.

A standard survey was conducted from February 3, 2020 through February 6, 2020, including investigation of multiple complaint intake numbers which were substantiated without deficiencies.

The facility was found not in substantial compliance with Medicare/Medicaid regulations related to privacy and confidentiality of residents' personal and medical information. Specifically, the facility failed to maintain privacy for four residents due to posting of signs with clinical and personal information in their rooms.

Complaint Intake Numbers GA00201874, GA00202286, GA00199887, GA00200982, GA00200924, and GA00201805 were investigated in conjunction with the standard survey and were substantiated without deficiencies.

A licensure survey was conducted at Briarwood Health and Rehabilitation Center from February 3, 2020 through February 6, 2020 to assess compliance with privacy and confidentiality regulations.

The facility failed to maintain privacy and confidentiality for four residents related to posting signs containing clinical and personal information in their rooms. Signs with care instructions and personal details were visible to others, contrary to facility policy and resident rights.

The Life Safety Code Survey was conducted to assess compliance with 42 CFR Subpart 483.70(a) and the NFPA 101 Life Safety Code 2012 Edition requirements for Medicare/Medicaid participation.

The facility was found not in substantial compliance with life safety code requirements due to multiple deficiencies including inoperable exit sign lighting, improperly marked and unlocked fire alarm circuit, damaged sprinkler head and escutcheon plate, and a door at the bottom of an employee stairwell failing to self-close, potentially placing residents and staff at risk.

An Abbreviated/Partial Extended Survey was conducted to investigate complaints GA00196854 and GA00196724.

None of the complaints were substantiated during the survey.

The investigation of complaints GA00196854 and GA00196724 found no substantiated issues.

A complaint survey was conducted to investigate complaints GA00194020 and GA00193580 by a Registered Nurse Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

The survey was complaint-related for complaints GA00194020 and GA00193580 and found no deficiencies.

A revisit survey was conducted to verify correction of deficiencies cited as a result of a complaint survey conducted on 2018-10-29.

All deficiencies cited during the complaint survey were found to be corrected during this revisit survey.

The revisit survey was conducted following a complaint survey (GA00192237) on 2018-10-29. All cited deficiencies were corrected.

A complaint survey was conducted to investigate complaint GA00192237 regarding alleged verbal abuse of a resident by a Certified Nursing Assistant (CNA).

The facility failed to ensure one resident was free from verbal abuse by not reporting the allegation to the State Agency, not formally investigating the complaint, and by continuing to assign the alleged perpetrator to provide care to the resident. The Administrator did not document or report the incident, and the alleged perpetrator was not suspended as required by facility policy.

The complaint was substantiated. The resident alleged verbal abuse by CNA BB during a transfer using a Hoyer lift, including disrespectful comments. The facility did not report the allegation to the State Agency or suspend the alleged perpetrator. The Administrator and Director of Nursing acknowledged failures in investigation and reporting.

A revisit survey was conducted to verify correction of deficiencies cited in the August 9, 2018 Standard Survey and to investigate Complaint GA00191778.

All deficiencies cited in the August 9, 2018 Standard Survey were found to be corrected. The complaint investigation was found to be unsubstantiated.

Complaint GA00191778 was investigated and found to be unsubstantiated.

A follow-up survey was conducted to verify that all previously cited survey tags had been corrected.

The follow-up survey noted that all previously cited survey tags have been corrected.

A standard survey was conducted from 8/6/2018 through 8/9/2018, including investigation of Complaint Intake Numbers 189487 and 189563, to assess compliance with Medicare/Medicaid regulations for long term care facilities.

The facility was found not in substantial compliance with infection prevention and control requirements, specifically failing to ensure staff followed contact isolation precautions and proper hand hygiene for a resident with C. difficile infection. Additionally, the facility failed to perform routine maintenance on air flow mattress pumps, with dirty filters potentially affecting five residents.

Complaint Intake Numbers 189487 and 189563 were investigated in conjunction with the standard survey.

The inspection was conducted to evaluate compliance with infection control procedures and safety standards, including proper use of contact precautions for a resident with Clostridium difficile and maintenance of air flow mattress equipment.

The facility failed to ensure proper infection control practices as a Certified Nurse Aide was observed not washing hands with soap and water after handling a meal tray from a resident on contact precautions for C. Diff. Additionally, maintenance failed to routinely clean air mattress pump filters, which were found dirty and potentially impeding air flow.

A Life Safety Code Survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and the National Fire Protection Association (NFPA) Life Safety Code standards.

The facility was found not in substantial compliance with life safety code requirements, including failure to provide documentation of the 5-year internal sprinkler system test, failure to maintain closing and latching of the janitor door in the kitchen, missing door knobs and lack of hold open magnets on basement smoke compartment doors, and failure to seal multiple penetrations with approved U.L. listed caulk above the basement smoke compartment ceiling.

A complaint survey was conducted to investigate complaint #GA00187524 by a Qualified Surveyor to determine compliance with Federal and State Long Term Care Requirements.

No deficiencies were cited during the complaint survey.

Complaint #GA00187524 was investigated and found to have no deficiencies.

An abbreviated/partial extended survey was conducted to investigate complaint GA00183387.

The complaint GA00183387 was found to be unsubstantiated.

Complaint GA00183387 was investigated and found to be unsubstantiated.

A revisit survey was conducted to verify correction of deficiencies cited in the prior standard survey conducted on 2017-09-18.

All deficiencies cited as a result of the 2017-09-18 standard survey were found to be corrected during the revisit survey.

A follow-up survey was conducted to verify that all previously cited survey deficiencies had been corrected.

The follow-up survey noted that all previously cited survey tags had been corrected.

A life safety code survey was conducted to assess compliance with Medicare/Medicaid participation requirements related to fire safety and electrical systems.

The facility was found not in substantial compliance due to failure to maintain documentation of monthly 30-minute load testing of the emergency generator, which could place residents at risk during an emergency.

A health revisit to the abbreviated survey of 7/24/2017 was conducted to determine if previously cited deficiencies had been corrected.

It was determined that the previously cited deficiencies had been corrected and no additional regulatory deficiencies were cited.

An abbreviated survey was conducted to investigate substantiated deficiencies related to food quality and resident complaints at Briarwood Health and Rehabilitation Center.

The facility failed to serve palatable food to four residents and did not address ongoing food concerns raised in Resident Council meetings. Multiple interviews and document reviews revealed consistent complaints about food taste, seasoning, and overcooking, despite no issues with food temperature.

The abbreviated survey was conducted to investigate complaints GA00174098 and GA00173828.

No deficiencies were cited during the abbreviated survey conducted from 4/25/17 through 4/26/17.

The visit was complaint-related, investigating complaints GA00174098 and GA00173828, with no deficiencies found.

An abbreviated survey was conducted to investigate complaint #GA00172166 on 03/18/2017.

The complaint was unsubstantiated and no deficiencies were cited during the survey.

Complaint #GA00172166 was investigated and found to be unsubstantiated.

A Health Revisit to the Abbreviated Survey of 12/4/16 was conducted from 2/15/17 through 2/17/17 to verify correction of previously cited deficiencies and to investigate complaints GA00170844, GA00169487, and GA00171704.

All previously cited deficiencies had been corrected. Complaints GA00169487 and GA00171704 were not substantiated. Complaint GA00170844 was substantiated but no regulatory deficiency was cited.

Complaints GA00169487 and GA00171704 were not substantiated. Complaint GA00170844 was substantiated; however, no regulatory deficiency was cited.

A Health Revisit to the Abbreviated Survey of 12/4/16 was conducted from 2/15/17 through 2/17/17 to verify correction of previously cited deficiencies and to investigate complaints GA00170844, GA00169487, and GA00171704.

All previously cited deficiencies had been corrected. Complaints GA00169487 and GA00171704 were not substantiated. Complaint GA00170844 was substantiated but no regulatory deficiency was cited.

Complaints GA00169487 and GA00171704 were not substantiated. Complaint GA00170844 was substantiated; however, no regulatory deficiency was cited.

An unannounced complaint survey was conducted to investigate Complaints # GA 00164724 and GA00167891 at Golden Living Center - Briarwood.

The facility was found in substantial compliance with Federal and State Long Term Care Requirements, and no deficiencies were cited.

The survey was complaint-related, investigating two complaints identified by numbers GA 00164724 and GA00167891. No deficiencies were found, indicating the complaints were not substantiated.