Briar Place Nursing

In the surveyor’s words

From the most serious findings on record at Briar Place Nursing, in the surveyor’s own words.

• Immediate jeopardy, isolatedF689Jul 24, 2025

  Based on interview and record review, the facility failed to secure the physical environment (window) in R1's room and implement appropriate precautions for a resident with a history of elopement risk, high suicidal risk, high risk per criminal background/ behavioral history, and assessed as being unsafe in the community unsupervised for one resident (R1) of three residents reviewed for elopement. This failure resulted in R1 removing the stationary window brackets that prevent the window from opening in his room, jumping out of the window, and eloping through the open back gate of the facility undetected by staff.The immediate jeopardy began on 7/3/25 at 10:28 PM, when R1 removed the stationary window brackets that prevent the window from opening in his room, jumped out of the window, and… […]

• Immediate jeopardy, isolatedF689Apr 26, 2024

  Based on interview and record review, the facility failed to effectively supervise a resident with history of drug abuse. This deficient practice affects one resident of three residents reviewed for change in condition. R28 had multiple incidents of noncompliance for bringing in contraband and R28 tested positive for cocaine once during R28's stay in the facility. R28 expired on [DATE] in the facility with cause of death as combined drug toxicity: Drug fentanyl Acetyl despropionyl fentanyl raised to the level of an Immediate Jeopardy. The Immediate Jeopardy began on [DATE] when R28 was found to be unresponsive at the bedside without breath. V1 (Administrator) and V2 (Director of Nursing) were notified of the Immediate Jeopardy on [DATE] at 10:18am. […]

• Immediate jeopardy, isolatedF600Dec 21, 2021

  Based on interview and record review, the facility neglected to provide services for the appropriate discharge of a dementia resident in accordance to their discharge policy, neglected to ensure the receiving facility could meet the medical and psychosocial needs of the resident, neglected to adequately communicate with the receiving facility, about a resident's pending discharge to confirm the residents acceptance to that facility and failed to complete discharge and transfer documentation for the receiving facility to determine residents acceptance prior to discharge, This applies to 1 of 3 residents (R1) reviewed for discharge and transfer. […]

• Immediate jeopardy, isolatedF800Jan 25, 2021

  Based on interview and record review, the facility failed to meet the resident's special dietary requirements by providing her with a food item that did not meet the criteria of the mechanically soft textured diet ordered. This failure resulted in a choking incident for (R1) of rhree residents reviewed for accidents and supervision. R1 was hospitalized and later expired due to asphyxia as a consequence of choking on food. This situation was identified as an immediate jeopardy. The immediate jeopardy began on [DATE]. The immediate jeopardy was identified on [DATE]. […]

• Actual harm, isolatedF602Sep 4, 2025

  Based on observation, interview, and record review, the facility failed to follow its abuse prevention policy by not protecting a resident from financial exploitation. This failure resulted in mental anguish and helplessness among 1 of 4 residents (R2) reviewed for theft and abuse in a sample of 4.The findings include:R2 is a [AGE] year-old female who was admitted on [DATE], and is independent in cognitive skills for daily decision-making, as per the Minimum Data Set (MDS) dated [DATE].On 9/2/25 at 12:05 PM, R2 stated, I originally had $1200 in my account, and I ran out $800 out of $1,200. I didn't give my bank card to anyone. Someone stole my card. The facility received my card through the mail, and I don't know why they left my mail under my pillow while I was admitted to the hospital. […]