Briarwood Health Care Center

Pharmacy Service Deficiencies

Ensure that residents are free from significant medication errors.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Have proper medical gas storage and administration areas.

Resident Rights Deficiencies

Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights.

Quality of Life and Care Deficiencies

Provide safe and appropriate respiratory care for a resident when needed.

Quality of Life and Care Deficiencies

Provide safe, appropriate dialysis care/services for a resident who requires such services.

Environmental Deficiencies

Make sure that a working call system is available in each resident's bathroom and bathing area.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Administration Deficiencies

Set up an ongoing quality assessment and assurance group to review quality deficiencies and develop corrective plans of action.

Pharmacy Service Deficiencies

Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

Services Deficiencies

Ensure heating and ventilation systems that have been properly installed according to the manufacturer's instructions.

Gas, Vacuum, and Electrical Systems Deficiencies

Meet requirements for the installation and maintenance of electrical systems.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Resident Assessment and Care Planning Deficiencies

Provide care by qualified persons according to each resident's written plan of care.

Quality of Life and Care Deficiencies

Ensure residents do not lose the ability to perform activities of daily living unless there is a medical reason.

Quality of Life and Care Deficiencies

Provide care and assistance to perform activities of daily living for any resident who is unable.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Nursing and Physician Services Deficiencies

Ensure that the resident and his/her doctor meet face-to-face at all required visits.

Quality of Life and Care Deficiencies

Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia.

Services Deficiencies

Have properly installed electrical wiring and gas equipment.

Gas, Vacuum, and Electrical Systems Deficiencies

Have generator or other power source capable of supplying service within 10 seconds.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Quality of Life and Care Deficiencies

Provide appropriate care for a resident to maintain and/or improve range of motion (ROM), limited ROM and/or mobility, unless a decline is for a medical reason.

Quality of Life and Care Deficiencies

Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

Quality of Life and Care Deficiencies

Provide enough food/fluids to maintain a resident's health.

Smoke Deficiencies

Have approved installation, maintenance and testing program for fire alarm systems.

Smoke Deficiencies

Inspect, test, and maintain automatic sprinkler systems.

Quality of Life and Care Deficiencies

Provide appropriate treatment and care according to orders, resident’s preferences and goals.

Infection Control Deficiencies

Provide and implement an infection prevention and control program.

Egress Deficiencies

Add doors in an exit area that do not require the use of a key from the exit side unless in case of special locking arrangements.

Quality of Life and Care Deficiencies

Provide activities to meet all resident's needs.

Egress Deficiencies

Have properly located and lighted "Exit" signs.

Smoke Deficiencies

Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

Smoke Deficiencies

Provide properly protected cooking facilities.

Smoke Deficiencies

Install corridor and hallway doors that block smoke.

Smoke Deficiencies

Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

Services Deficiencies

Have elevators that firefighters can control in the event of a fire.

Gas, Vacuum, and Electrical Systems Deficiencies

Ensure proper usage of power strips and extension cords.

A survey, prompted by #CO1936676, #CO1936677 and #CO1936678 was conducted 7/15/25 to 7/16/25. One deficiency was cited. Based on record review and interviews, the facility failed to ensure one (#5) of 12 residents reviewed for medication management were free from significant medication errors out of 12 sample residents. Resident #5 was admitted to the facility on 12/10/21 with diagnoses of hemiplegia and hemiparesis (weakness and paralysis on one side of the body) following cerebrovascular disease (a condition that affects the blood vessels in the brain) and epilepsy (seizure disorder).On 6/7/25 the facility received a delivery from the pharmacy. Licensed practical nurse (LPN) #1 signed for the delivery and did not open the box to check the contents. LPN #1 placed the box in the medication room. When LPN #1 went to administer Resident #5’s Dilantin medication (a medication used to prevent seizures) on 6/20/25 and 6/21/25, she was unable to locate the medication. This resulted in Resident #5 missing three consecutive doses of Dilantin. On 6/21/25 Resident #5 was transferred to the hospital for a possible seizure. The resident was monitored with a continuous electroencephalography (cEEG) (monitors brain activity), which showed focal status epilepticus (a prolonged seizure) as well as secondary generalized seizures. The resident was treated in the hospital with anticonvulsants intravenously (IV). Specifically, the facility failed to ensure Resident #5 was given her antiseizure medication as ordered. Findings include:Record review and interviews confirmed the facility corrected the deficient practice prior to the onsite investigation on 7/15/25 to 7/16/25, resulting in the deficiency being cited as past noncompliance with a correction date of 6/27/25. I. Medication error on 6/20/25 and 6/21/25On 6/7/25 LPN #1 received and signed for a delivery from the pharmacy. She did not open the box and inventory the contents. She placed the delivered box in the medication room. On 6/20/25 at 6:55 p.m. LPN #1 documented she was unable to administer Dilantin 150 milligrams (mg) due to not having the medication. On 6/21/25 at 8:21 a.m. LPN #1 document..

Based on documentation review and staff interview, it was determined that the facility failed to maintain smoke dampers in accordance with Life Safety Code Section NFPA 105. This was evidenced by the following:1. The most recent fire damper inspection report from 4/26/2023 stated there were two fire dampers that failed inspection/testing.NFPA 105, 6.5.1 Smoke dampers for dedicated and non-dedicated smoke control systems shall be inspected and tested in accordance with NFPA 92A, Standard for Smoke-Control Systems Utilizing Barriers and Pressure Differences.6.5.2* Each damper shall be tested and inspected one year after installation. The test and inspection frequency shall then be every 4 years, except in hospitals, where the frequency shallbe every 6 years.6.5.3 Care shall be exercised that all tests are completed in a safe manner wearing the appropriate personal protective equipment.6.5.4 Full unobstructed access to the damper shall be verified and corrected as required.This deficiency has the potential to affect occupants, who might include residents, staff, and visitors within the entire facility. Deficient items were discussed with the administrator and maintenance director at the exit conference. Based on observation during the course of the survey it was determined the facility failed to maintain a hazardous area in accordance with NFPA 99. This was evidenced by the following:1. CO2 cylinders are not properly secured (next to the soda machine in the basement).NFPA 99, Section 11.6.2.3 Cylinders shall be protected from damage by means of the following specific procedures:Freestanding cylinders shall be properly chained or supported in a proper cylinder stand or cart.This deficiency can potentially affect occupants, including staff and visitors within the basement smoke compartment. Deficient items were identified during the survey and discussed with the Administrator at the exit conference. This survey was conducted in accordance with the Federal Register at Section 42 CFR 483.70(a).The initial comments (ID Prefix Tag K-000) are informational only and are a representation of the facility' s general characteristics.The facility consists of two (2), four story (4) Type 1 (222) structures licensed for two hundred one (201) beds, and the facility reports a census of sixty eight (68) at the time of the survey. Building A-1 (West Building) and building A-2 (East building) are both protected by a complete NFPA 13 fire sprinkler system. Each building contains their own sprinkler and fire alarm system and they are not interconnected. The two buildings are connected with a bridge on the third level and a tunnel on the basement level. The bridge and tunnel are separated with 2 hour fire rated construction and opening protectives on both sides of the East and West buildings.The facility was surveyed on October 30, 2024 for compliance to fire safety requirements using the National Fire Protection Association (NFPA) 2012 Life Safety Code, Chapter 19, Existing Facilities. The facility will meet these requirements when the following deficiencies are corrected.The deficiencies were discussed with the Maintenance Director during the walk-through inspection of the building and the survey concluded with a discussion of the deficiencies with the facility Maintenanc..

A Recertification Emergency Preparedness Survey was conducted by Healthcare Management Solutions, LLC on behalf of the Colorado Department of Public Health and Environment (CDPHE) on 09/30/24 through 10/03/24. There were no deficiencies cited. A Recertification survey was conducted by Healthcare Management Solutions, LLC on behalf of the Colorado Department of Public Health and Environment (CDPHE). Four deficiencies were cited. Based on observation, interview, record review, and facility policy review, the facility failed to ensure four residents (Resident (R) 2, R6, R30, and R41) out of a total sample of 20 residents reviewed for respiratory services received appropriate care of their oxygen tubing. This created the potential for infection.Findings include:Review of the facility policy titled "Oxygen Administration (Safety, Storage, and Maintenance)", issued 12/03/18 and revised 02/27/24 and under the sub section titled "Infection Control" indicated " ...Change oxygen supplies weekly and when visibly soiled. Equipment should be labeled with patient name and dated when set-up or changed out ..."1. Review of.. Based on observation, record review, interview, and review of facility policy, the facility failed to ensure two residents (Resident (R)51 and R72) out two residents observed with catheter bags out of 20 sampled residents reviewed had dignity bags for their use of a foley catheter. This failure had the potential to cause embarrassment and loss of dignity to the two residents.Findings include:Review of the facility' s policy, provided by the facility, titled "Dignity" with an issued date of 05/06/19 and reviewed on 09/25/23 revealed "Each resident has the right to be treated with dignity and respect. "The procedure was to "promote resident independence and dignity while dining" a.. Based on observation, record review, interview, and review of facility policy, the facility failed to ensure one resident (Resident (R)51) observed out of 20 sampled residents had their call light within reach. This failure had the potential to cause R51 needs to not be met .Findings include:Review of the facility' s policy, provided by the facility, titled "Keeping a Resident Room in Order," issued :08/09/2019 and reviewed 06/02/24 revealed "The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely, call lights must be within easy reach of the resident in bed and out of bed."Review of R51' s "Face S.. Based on record review, interview, and review of facility policy, the facility failed to ensure weights were documented for one (Resident (R) 31) of two residents reviewed for dialysis out of a sample of 20 residents. This had the potential for the resident to have unmet care needs. Findings include:Review of the facility policy titled "Hemodialysis Offsite Policy" effective 04/24/19 and last reviewed 09/06/24 indicated that under the "Procedure" section revealed, "the facility should weigh the resident." Under the "Day of Dialysis" section indicated, "the facility should observe the vascular access site prior to dialysis and initiate the "Pre/Post Dialysis Communication Form" to be sent to the dialysi..