Above average — CMS composite of the measures below.
The next survey window likely opens around November 2026
Estimate from public CMS data, current as of August 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Briarwood Healthcare Center during CMS and state inspections, most recent first.
A facility failed to follow fall interventions for two residents with documented fall risk. One resident with severe cognitive impairment and repeated room falls was left in a wheelchair in the room despite care plan directions not to leave the resident unattended there or to keep the wheelchair in the hallway when in the recliner. Another resident with intact cognition and multiple room falls had a walker placed out of reach during observation, even though the care plan directed staff to keep the walker within reach and hold the gait belt during assistance. Staff interviews showed inconsistent understanding of the interventions, and the DON stated staff needed to follow through with the interventions in place.
The facility failed to screen, educate, and offer pneumococcal vaccinations to residents as required. Four residents were not properly screened or offered necessary vaccines, with some missing additional recommended doses. The ADON mentioned checking the Immunization Registry upon admission, but the DON was unaware of the vaccination requirements, leading to residents not being up to date.
A facility failed to update the comprehensive assessment for a resident with severe cognitive impairment and a history of falls. The MDS did not document the use of bed or chair alarms, which were implemented after a significant fall. Staff interviews revealed that the alarms were placed following family prompts and after the resident attempted self-transfers. The MDS Coordinator acknowledged missing updates, despite the facility's policy requiring ongoing assessments.
A resident with severe cognitive impairment was administered crushed Mucinex ER tablets despite a physician's order not to crush them. An LPN crushed the medication, believing the order allowed it, and administered it mixed in pudding. The DON expected pharmacy collaboration for alternative forms when crushing is prohibited.
Failure to Follow Fall Interventions for Two Residents
Penalty
Summary
The facility failed to implement fall interventions per the care plan for two residents who were reviewed for falls. Resident #3 had a BIMS score of 3 out of 15, indicating severe cognitive impairment, and diagnoses that included traumatic brain injury and depression. The resident used a walker and required partial/moderate assistance for transfers. The care plan identified the resident as high risk for falls due to gait and balance problems and documented interventions including not leaving the resident unattended in the wheelchair in the room and keeping the wheelchair in the hallway when in the recliner. Resident #3 experienced three falls in the room. On one occasion, the resident was leaning forward in the wheelchair and dropped to his knees while in the room. On another, the resident was found sitting on the floor in front of the recliner after attempting to transfer from the wheelchair to the recliner. On a third occasion, the resident leaned forward in the wheelchair while trying to pick something up off the floor and fell in the room. Staff interviews showed differing understanding of the intervention, with some CNAs stating the resident could be in the wheelchair in the room unsupervised for a little while, while the DON stated staff needed to follow through with the interventions put in place. Resident #4 had a BIMS score of 14 out of 15, indicating intact cognition, and diagnoses that included stroke, diabetes mellitus, and depression. The resident required supervision/touching assistance with transfers and walking, used a front wheeled walker, and had care plan interventions that included a reminder sign to call for assistance, staff holding onto the gait belt, and keeping the walker within reach. The resident had multiple falls in the room, including falls while reaching for the walker, turning while walking, and attempting to move without assistance. During observation, the resident’s walker was positioned about 3 feet away against the closet doors while the resident sat in a recliner. Staff interviews showed inconsistent understanding of the care plan, with several CNAs stating the walker should be kept away from the resident, while the DON stated the walker should be beside the recliner and that staff should keep a hand on the gait belt at all times when using it.
Failure to Screen and Offer Pneumococcal Vaccinations
Penalty
Summary
The facility failed to adequately screen, educate, and offer pneumococcal vaccinations to residents, as required by CDC guidelines. This deficiency was identified through interviews, clinical record reviews, and policy reviews. Specifically, four out of five residents reviewed for immunizations were not properly screened or offered the necessary pneumococcal vaccines. For instance, one resident had received a Pneumococcal polysaccharide vaccine prior to admission but lacked the additional recommended dose of a Pneumococcal conjugate vaccine. Another resident had received a Pneumococcal conjugate vaccine before admission but was missing the subsequent Pneumococcal polysaccharide vaccine dose. The facility's failure to comply with vaccination protocols was further highlighted by the lack of documentation and awareness among staff. The Assistant Director of Nursing mentioned that the Immunization Registry Information System was checked upon admission, but the Director of Nursing admitted to being unaware of the requirements for screening and offering pneumococcal vaccinations. This oversight resulted in residents not being up to date with their vaccinations, as evidenced by the facility's own policy, which mandates assessment of all residents for pneumococcal vaccination upon admission.
Failure to Update Comprehensive Assessment for Resident
Penalty
Summary
The facility failed to update the comprehensive assessment to ensure accuracy for one resident, identified as Resident #16. The Minimum Data Set (MDS) report for this resident did not document the use of a bed or chair alarm, despite the resident having a history of falls and severe cognitive impairment, as indicated by a Brief Interview for Mental Status (BIMS) score of 3 out of 15. Observations and staff interviews revealed that alarms were placed on the resident's bed and recliner after a fall approximately two months prior, due to the resident's attempts to self-transfer to the bathroom unassisted. However, these interventions were not reflected in the MDS, indicating a lapse in updating the resident's care plan and assessment. Interviews with staff, including Certified Nursing Assistants (CNAs) and the Director of Nursing (DON), highlighted that the alarms were implemented following family prompts and after a significant fall resulting in a hip fracture. The MDS Coordinator admitted to occasionally missing updates in the MDS, despite having added interventions to the care plan. The facility's policy on comprehensive assessment and reassessment requires ongoing assessment throughout the resident's stay, but this was not adhered to in this case, leading to the deficiency.
Medication Administration Error Due to Crushing Prohibited Tablets
Penalty
Summary
The facility failed to adhere to a physician's order regarding the administration of medication for a resident with severe cognitive impairment. The resident, diagnosed with unspecified dementia, shortness of breath, and allergic rhinitis, had a physician's order specifying that Mucinex 600mg ER tablets should not be crushed. However, during an observation, an LPN was seen crushing the Mucinex tablets along with other medications and administering them to the resident mixed in pudding. This action was contrary to the specific instruction not to crush the medication. The LPN explained that the computer system indicated that medications could be crushed and that typically, if a medication should not be crushed, a substitute is provided by the pharmacy. The LPN believed the order had been changed to allow all medications to be crushed. The Director of Nursing stated that if there is an order not to crush certain medications, the facility should work with the pharmacy to obtain a liquid form or a capsule that can be opened. The facility's medication administration policy requires staff to verify medication orders against the MAR and ensure proper administration, which was not followed in this instance.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Iowa City
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Oaknoll Retirement Residence | 0.5 mi | ★★★★★ | 0 | 0 |
| Iowa City Rehab & Health Care | 3.5 mi | ★★★★★ | 27 | 0 |
| Lantern Park Specialty Care | 4.3 mi | ★★★★★ | 0 | 0 |
| Windmill Manor | 5 mi | ★★★★★ | 11 | 0 |
| Crestview Specialty Care | 10.2 mi | ★★★★★ | 15 | 1 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release August 2026) and official state health department websites.