Barclay Friends

In the surveyor’s words

From the most serious findings on record at Barclay Friends, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF851Jun 13, 2025

  Based on facility requirements according to the Affordable Care Act (ACA), review of Payroll Based Journal (PBJ) Staffing Data Reports, and staff interview, it was determined that the facility failed to electronically submit accurate direct care staffing information for one of the last four quarters (Quarter One of 2025). Findings include: Review of Section 6106 of the ACA requires facilities to electronically submit direct care staffing information (including agency and contract staff) based on payroll and other auditable data to the Centers for Medicare and Medicaid Services (CMS). […]

• No harm, potential for more than minimal, isolatedF641Aug 12, 2022

  Based upon clinical record review and observation, it was determined that the facility failed to accurately complete a Minimum Data Set assessment relating to restraints for one of 24 residents reviewed (Resident 37). Findings include: Review of Resident 37's Quarterly Minimum Data Set (MDS - periodic assessment of resident needs) dated June 9, 2022 revealed Resident 37 utilized a trunk restraint while in a chair or out of bed. Review of Resident 37's clinical record failed to reveal evidence that a trunk restraint was in use. Observations conducted of Resident 37 during the survey failed to reveal a trunk restraint in use. Interview with the Director of Nursing on August 12, 2022 at approximately 11:00 a.m. […]

• No harm, potential for more than minimal, isolatedF684Aug 12, 2022

  Based on review of facility policy, review of clinical records, and interviews with staff, it was determined that the facility failed to ensure that physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Findings include: Review of facility policy, Weight of Resident, revised January 2018, revealed the Physician, Registered Dietitian, and Power of Attorney will be notified if there is a 5 lb. weight gain/loss in one month. Review of Resident 51's physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Review of Resident 51's weights revealed a weight of 124 lbs on April 23, 2022, and a weight of 147 lbs on May 23, 2022 (a gain of 23 lbs in one month). […]