Inspection Reports for
Briarwood Nursing and Rehabilitation Center, Inc.
516 So Rodney Parham Rd, Little Rock, AR, 72205
Back to Facility ProfileDeficiencies (last 3 years)
Deficiencies (over 3 years)
5.7 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
10% worse than Arkansas average
Arkansas average: 5.2 deficiencies/yearDeficiencies per year
12
9
6
3
0
Inspection Report
Complaint Investigation
Deficiencies: 1
Date: May 15, 2025
Visit Reason
The inspection was conducted due to an allegation of verbal and physical abuse reported by Resident #317, which the facility failed to immediately report to the Office of Long-Term Care (OLTC).
Complaint Details
The complaint involved an allegation of verbal and physical abuse by two CNAs against Resident #317. The allegation was not reported to the State Agency by the facility. The police investigated and found no evidence of abuse. The facility's internal investigation also found no abuse, and the family was satisfied with the outcome.
Findings
The investigation found no evidence to support the abuse allegation. The facility conducted an internal investigation, police were involved, and the family was informed and satisfied with the results. No physical signs or witnesses of abuse were found.
Deficiencies (1)
Failure to timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities.
Report Facts
Resident ID: 317
Assessment Reference Date: Mar 17, 2025
BIMS score: 13
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Assistant Director of Nursing | Assistant Director of Nursing (ADON) | Conducted internal investigation and stated no findings of abuse |
| Administrator | Administrator | Interviewed regarding abuse allegation and reporting |
| Director of Nursing | Director of Nursing (DON) | Interviewed about reporting of abuse allegation |
| Medical Director | Medical Director | Familiar with Resident #317 and commented on abuse allegation reporting |
Inspection Report
Complaint Investigation
Deficiencies: 3
Date: May 15, 2025
Visit Reason
The inspection was conducted to investigate complaints related to catheter care, garbage disposal, and infection prevention practices at Briarwood Nursing and Rehabilitation Center.
Complaint Details
The investigation was complaint-driven focusing on catheter care, infection control, and sanitation issues. The complaint was substantiated with findings of improper catheter bag handling, inadequate garbage disposal, and failure to follow infection prevention protocols.
Findings
The facility failed to ensure catheter bags did not touch the floor, increasing infection risk for Resident #42. Garbage and refuse were improperly disposed of around dumpsters. Staff failed to follow Enhanced Barrier Precautions during wound care for Resident #7, specifically not wearing gowns during dressing changes.
Deficiencies (3)
Failed to ensure catheter bag did not touch the floor for Resident #42, risking infection.
Failed to ensure garbage and refuse were disposed of properly around dumpsters.
Failed to ensure staff followed Enhanced Barrier Precautions during wound care for Resident #7; nurse did not wear a gown.
Report Facts
Observations of catheter bag touching floor: 2
Dumpster observations: 2
In-service training date: Mar 14, 2025
MDS Assessment Reference Date: Apr 29, 2025
MDS Assessment Reference Date: Jan 27, 2025
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Certified Nursing Assistant (CNA) #1 | Described catheter bag hanging procedure | |
| Licensed Practical Nurse (LPN) #4 | Acknowledged catheter bag should not touch floor | |
| Certified Nursing Assistant (CNA) #6 | Admitted placing catheter bag on floor during personal care | |
| Licensed Practical Nurse (LPN) #3 | Described catheter care and observed not wearing gown during wound care | |
| Assistant Director of Nursing (ADON) | Explained catheter bag care expectations and infection control | |
| Infection Preventionist (IP) | Discussed catheter care and antibiotic stewardship | |
| Medical Director | Stated catheter bags should not be on the floor and expectations for infection control | |
| Maintenance Director (MD) | Responsible for dumpster area maintenance and described observations | |
| Administrator | Discussed dumpster maintenance and infection control policies | |
| Advance Practice Registered Nurse (APRN) | Present during wound care observation | |
| Assistant Administrator | Agreed on expectations for Enhanced Barrier Precautions |
Inspection Report
Routine
Deficiencies: 9
Date: Mar 7, 2024
Visit Reason
The inspection was conducted to assess compliance with regulatory requirements related to resident assessments, care planning, infection control, safety, dietary services, and overall facility operations.
Findings
The facility was found deficient in timely and accurate completion of Minimum Data Set (MDS) assessments, development and implementation of care plans addressing residents' needs, proper oral care and hygiene practices, environmental safety, oxygen therapy management, dietary services including proper meal portions and food safety, and infection prevention and control practices including hand hygiene and proper storage of personal care items.
Deficiencies (9)
Failed to complete discharge and admission Minimum Data Set (MDS) assessments in a timely manner for multiple residents.
Failed to ensure accurate MDS assessments reflecting anticoagulant medication use.
Failed to develop and implement care plans addressing pressure ulcers, tube feedings, anticoagulant, antianxiety, and antidepressant medications.
Failed to provide proper oral care and hygiene, including improper storage of toothbrush and denture cup.
Failed to ensure environmental safety by leaving storage room door unsecured and using a mechanical lift with missing safety clip.
Failed to ensure oxygen tubing was dated and stored correctly to prevent respiratory complications.
Failed to ensure residents received double portions as part of dietary interventions to prevent weight loss and malnutrition.
Failed to maintain clean and sanitary food storage areas, including unlabeled and expired food items, uncovered drinks, and unclean refrigerators.
Failed to implement infection prevention and control program including improper hand hygiene during resident care and improper storage of personal care items.
Report Facts
Residents affected by untimely discharge MDS assessments: 7
Residents affected by untimely admission MDS assessments: 2
Residents potentially affected by untimely discharge MDS assessments: 135
Residents potentially affected by untimely admission MDS assessments: 124
Residents affected by inaccurate anticoagulant MDS coding: 8
Residents affected by lack of care plans for pressure ulcers: 6
Residents affected by lack of care plans for tube feedings: 2
Residents affected by lack of care plans for anticoagulant medications: 25
Residents affected by lack of care plans for antianxiety medications: 18
Residents affected by lack of care plans for antidepressant medications: 48
Residents affected by improper oral care: 23
Residents affected by improper bathing hygiene: 4
Residents affected by unsafe environment due to unsecured storage room: 6
Residents affected by unsafe mechanical lift: 1
Residents affected by improper oxygen tubing management: 11
Residents receiving double portions: 1
Residents potentially affected by food safety issues: 99
Employees mentioned
| Name | Title | Context |
|---|---|---|
| MDS #1 | MDS Coordinator | Admitted being behind on discharge and admission MDS assessments |
| Assistant Director of Nursing | ADON | Interviewed regarding policies on MDS, care plans, dental care, lift use, oxygen tubing, and hand hygiene |
| MDS #2 | MDS Coordinator | Interviewed regarding anticoagulant medication coding and care plan development |
| Certified Nursing Assistant #6 | CNA | Observed improper storage of toothbrush and denture cup |
| Certified Nursing Assistant #2 | CNA | Observed improper bathing hygiene practices |
| Certified Nursing Assistant #3 | CNA | Observed improper bathing hygiene practices |
| Certified Nursing Assistant #4 | CNA | Observed improper hand hygiene during meal service |
| Certified Nursing Assistant #5 | CNA | Observed improper hand hygiene during meal service |
| Licensed Practical Nurse #1 | LPN | Interviewed regarding bathing hygiene and oxygen tubing storage |
| Licensed Practical Nurse #2 | LPN | Interviewed regarding oxygen tubing storage |
| Licensed Practical Nurse #3 | LPN | Interviewed regarding special diet and meal portions |
| Licensed Practical Nurse #4 | LPN | Interviewed regarding oxygen tubing change frequency |
| Certified Nursing Assistant #8 | CNA | Observed improper handling of cups during meal service |
| Certified Nursing Assistant #9 | CNA | Secured storage room door and explained importance of safety |
| Dietary Manager | Dietary Manager | Interviewed regarding food safety, meal portions, and kitchen practices |
| Certified Nursing Assistant #10 | CNA | Observed uncovered drinks on dining hall cart |
Inspection Report
Annual Inspection
Deficiencies: 1
Date: Feb 15, 2024
Visit Reason
The inspection was conducted to assess compliance with care plan development and revision requirements, specifically focusing on the facility's failure to review and revise care plans and reassess interventions related to resident falls.
Findings
The facility failed to revise care plans and implement interventions for Resident #2 related to multiple falls over the past three months, potentially affecting eight residents. Interviews with the Director of Nursing and Assistant Director of Nursing confirmed that care plans were not revised as required and that no policy for care plan revision existed.
Deficiencies (1)
Failure to review and revise care plans and reassess effectiveness of interventions to meet resident needs for Resident #2 related to frequent falls.
Report Facts
Number of falls for Resident #2: 7
Days to develop complete care plan: 7
Number of residents potentially affected: 8
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Interviewed regarding care plan revisions and processes related to falls | |
| Assistant Director of Nursing | Interviewed regarding care plan revisions for Resident #2 and policy absence |
Inspection Report
Routine
Census: 103
Deficiencies: 3
Date: Dec 9, 2022
Visit Reason
The inspection was conducted to assess compliance with medication storage and food safety standards at Briarwood Nursing and Rehabilitation Center.
Findings
The facility failed to ensure medication carts were locked when unattended, risking resident access to medications, and failed to maintain clean and sanitary conditions in kitchenettes, including unclean ice machines, expired food, and improper hand hygiene by dietary staff, potentially affecting resident safety.
Deficiencies (3)
Medication cart was left unlocked when unattended, risking access by mobile residents.
Ice machines in kitchenettes were unclean with black residue and expired food was present.
Dietary staff failed to wash hands properly before handling clean equipment or food items.
Report Facts
Residents affected: 14
Total census: 103
Residents affected: 102
Expired food date: Oct 28, 2022
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Licensed Practical Nurse (LPN) #1 | Left medication cart unlocked | |
| Licensed Practical Nurse (LPN) #2 | Locked medication cart after LPN #1 left it unlocked | |
| Director of Nursing (DON) | Provided policy and confirmed medication cart should be locked | |
| Dietary Employee (DE) #1 | Provided list of residents and participated in ice machine cleaning observation | |
| Dietary Employee (DE) #2 | Observed failing to wash hands properly before food handling | |
| Dietary Employee (DE) #3 | Observed contaminating gloves and improper hand hygiene during food preparation | |
| Maintenance Supervisor | Reported cleaning ice machine once a month |
Viewing
Loading inspection reports...
