Briarwood Village

Based on review of the facility fire drill records and staff interview, the facility failed to ensure fire drills were conducted at least once on each shift every three months. This had the potential to affect all residents residing in the facility. The facility census was 52.

Findings include:

Review of the facility fire drill records revealed no evidence the facility completed any fire drills during the second quarter of 2024 (April, May, and June).

Interview on 02/19/25 at 1:50 P.M. with Maintenance Director (MD) #259 confirmed the facility had no evidence of fire drills being conducted in April, May, or June of 2024.

This violation represents continued non-compliance from the survey completed 10/24/22.

Based on review of the facility fire prevention training documentation and staff interview, the facility failed to conduct annual staff fire prevention training as required. This had the potential to affect all residents residing in the facility. The facility census was 52.

Findings include:

Review of the staff fire prevention training documentation revealed no evidence the facility conducted fire prevention training in 2024.

Interview on 02/19/25 at 1:50 P.M. with Maintenance Director (MD) #259 confirmed the facility had no evidence of staff fire prevention training in 2024.

Based on review of the employee files and staff interview the facility failed to ensure staff had received first aid training within 60 days of hire. This had the potential to affect all 53 residents residing in the facility.

Findings include:

Review of the employee file of Resident Assistant (RA) #207 revealed a hire date of 06/10/22 and the file had no documentation any first aid training had been completed.

Review of the employee file of RA #216 revealed a hire date of 06/10/22 and the file had no documentation any first aid training had been completed.

Interview on 10/20/22 with Human Resource Director #248 provided verification of the lack of first aid training for RA #207 and #216.

Based on medical record review and staff interview the facility failed to ensure falls assessments were completed on two residents (#29 and #50) of two residents reviewed for complete assessments. The facility census was 53.

Findings include:

1. Review of the medical record of Resident #29 revealed an admission date of 01/20/21. Diagnoses included unspecified dementia without behavioral disturbance, type II diabetes mellitus without complications, and hypothyroidism.

The record had no documentation a falls assessment was completed.

2. Review of the medical record of Resident #50 revealed an admission date of 01/01/18. Diagnoses included intestinal malabsorption, hypertension, heart disease, obstructive and reflux uropathy, depression, atherosclerotic heart disease, transient ischemic attack, acidosis, and disorder of bilirubin metabolism.

The record had no documentation a falls assessment was completed.

Interview on 10/20/22 at 1:47 P.M. with Director of Clinical Services provided verification of the lack of falls assessments.

Based on record review, staff interview, and policy review, the facility failed to conduct fire drills quarterly on each shift. The facility also failed to conduct the fire drills at varied times. This had the potential to affect all 53 residents residing in the facility.

Findings include:

Review of the facility fire drills revealed no fire drill had been conducted on the evening shift (2:00 P.M. to 10:00 P.M.) for the fourth quarter of 2021, or the first and second quarters of 2022. The drills further revealed the times were not varied and residents were not evacuated on the night shift (10:00 P.M. to 6:00 A.M.)

Interview on 10/20/22 at 10:55 A.M. with Executive Director and Maintenance Supervisor #232 revealed the fire drills had not been conducted on the evening shifts in the fourth quarter of 2021, or the first and second quarters in 2022. The drills were not conducted at varied times and all four night shift drills were silent and no residents were evacuated.

Review of the facility policy titled Drills dated 03/30/12 revealed fire drills will be conducted monthly on each shift.

Based on review of the emergency drills, staff interview, and policy review, the facility failed to ensure disaster drills were conducted as required. This had the potential to affect all 53 residents residing in the facility.

Findings include:

Review of there emergency drills revealed no tornado drill nor any other drill had been conducted for the past 12 months.

Interview on 10/20/22 at 10:55 A.M. with Executive Director and Maintenance Supervisor #232 revealed no emergency drill, including a tornado, was completed in the past 12 months.

Review of the facility policy titled Drills dated 03/30/12 revealed a disaster drill will be conducted biannually.

Based on observation, staff and resident interview, review of the incident log, and policy review, the facility failed to ensure water temperatures remained in a safe range. This directly affected four residents (#02, #03, #46, and #50) and had the potential to affect all 53 residents residing in the facility.

Findings include:

Observation on 10/18/22 at 10:20 A.M. revealed the water in the room of Resident #50 recorded a temperature of 129.9 degrees Fahrenheit (F) in the bathroom sink and 126.7 degrees F in the kitchen sink. The water temperature in the room of Residents #02 and #03 was recorded at 124.3 F in the bathroom and 126.7 F in the kitchen. The residents said they like the warmer water temperatures.

Interview and retest of the water temperature on 10/18/22 at 10:43 A.M. with Maintenance Supervisor #232 revealed the water temperature in the room of Resident #50 read 122.5 F in the kitchen and 129.4 in the bathroom. The water temperature in the room of Residents #02 and #03 read 124.5 F in the kitchen and 127.9 F in the bathroom. The water temperatures in the room of Resident #46 read 125.1 F in the kitchen and 124.2 F in the bathroom. Each of the three rooms were in separate hallways.

Review of the incident log revealed no burns were identified from hot water.

Review of the facility policy titled Hot/Cold Water Temperatures -- OH dated 06/14/17 revealed the manor's standard for water temperatures servicing resident and visitor areas is 110 through 117 degrees F.