Briarcliff Manor Center for Rehab and Nursing Care

Inspectors wroteBased on record review, interviews, and observations conducted during survey the facility failed to ensure residents receive services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for 1 of 5 residents reviewed for antibiotics. Specifically, Resident #5 was determined to have a urinary tract infection on 4/13/26, refused antibiotics in all forms and there was no documented follow up. Resident was admitted to hospital on [DATE] with a urinary tract infection.

Inspectors wroteBased on record review, interviews, and observations conducted during a survey, the facility failed to ensure a resident was provided with the necessary services to attain or maintain the highest practicable physical, mental, and psychosocial well-being in accordance with the comprehensive assessment and plan of care for 1 of 5 residents reviewed for behavioral health. Specifically, Resident #5 refused 144 out of 178 doses of antipsychotic medications from March 2026 to June 2026 that contributed to symptoms of catatonia (withdrawal, intermittent mutism and posturing), weight loss, urinary tract infection and admission to hospital on 6/7/26.

Inspectors wroteBased on observation, interview, and record review conducted during the abbreviated survey (NY00383393), the facility did not ensure a resident remained free from physical abuse. This was evident for one (1) (Resident #1) of four (4) total sampled residents. Specifically, Resident #1 reported they were hit in their groin by Certified Nurse Aide #3 on 6/11/2025 at approximately 1:30 AM. This resulted in psychosocial harm that did not rise to level of Immediate Jeopardy.

Inspectors wroteBased on observation, interview, and record review during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure residents had the right to a dignified experience for 1 of 4 residents (Resident #24) reviewed for dignity. Specifically, Resident #24 was observed multiple times after meals with food/crumbs on their chin and their gown.

Inspectors wroteBased on record review, observations, and interviews conducted during a recertification survey from 03/05/2025 to 03/12/2025, the facility did not ensure that the residents' advance directives were accurate for 1 (Resident # 82) of 24 residents reviewed. Specifically, Resident #82's Medical Orders for Life Sustaining Treatment form was changed from Do Not Resuscitate (allow a natural death if the heart stops beating or resident stops breathing) to Full Code (perform Cardio-Pulmonary Resuscitation) and the physician orders and facility identifiers (system used to alert staff the resident's code status) were not updated to reflect the resident's wishes.

Inspectors wroteBased on observation and interview conducted during the recertification survey conducted from 3/5/25 to 3/12/25, the facility did not ensure that a clean, comfortable, and homelike environment was provided. Specifically, room C-19-B had broken window clips, room C-9-B had a broken radiator cover, a window shade that was stained, and black scuff marks on the wall between the window and resident dresser, room A-17 had a faulty window unit and faulty sealed Packaged Terminal Air Conditioner unit which allowed cold outside air to enter the room.

Inspectors wroteBased on observations, interviews and record reviews conducted during a recertification survey from 3/5/25 to 3/12/25 it was determined that for 1 of 1 residents (Resident #10) reviewed for skin conditions the facility did not ensure that injuries of unknown origin were reported to the state agency. Specifically, the state department was not notified after the 3/4/25 Accident/Incident Report documented Resident #10 was observed with discoloration that suddenly appeared on the right side of the resident's face.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification survey from 3/5/25-3/12/25, the facility did not ensure each Resident who was unable to carry out activities of daily living received the necessary care and services to maintain good personal hygiene for 2 (Residents #52 and #57) of 3 Residents reviewed for Activities of a Daily Living. Specifically, Resident #52 and #57 who required dependent assistance with Activities of Daily Living, were observed during multiple observations with fingernails that were long and ungroomed.

Inspectors wroteBased on observation, interview, and record review during the recertification survey from 3/5/25 to 3/12/25, the facility did not ensure appropriate care was provided in accordance with professional standards of practice for 1 of 1 residents (Resident #10) reviewed for Skin Conditions. Specifically, on 2/18/25 the registered nurse was not made aware, and there was no documented evidence that a registered nurse assessment was conducted after Resident #10 was hit in the face with the bed control while cares were being provided by Certified Nurse Aide #7.

Inspectors wroteBased on observations, record review and interviews conducted during the Recertification survey from 3/5/2025 to 3/12/25, the facility did not ensure that 1 of 2 residents (Resident #34) reviewed for Respiratory Care was provided with such care, consistent with the professional standards of practice. Specifically, Resident #34, had a physician's order for oxygen to be administered via nasal cannula at 3 liters per minute, and was observed multiple times with the oxygen rate not consistent with the physicians' order. Additionally, there was no signage present indicating oxygen was being utilized in Resident #34's room.

Inspectors wroteBased on interview, and record review conducted during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure that sufficient staff was available to meet the needs of all residents on 30 days reviewed. Specifically, actual staffing levels were below minimum levels on the following dates (2/2/2/25, 2/3/25, 2/4/25, 2/8/25, 2/9/25, 2/10/25, 2/12/25, 2/16/25, 2/17/25, 2/24/25, 2/25/25, 3/1/25, and 3/3/25).

Inspectors wroteBased on interview and record review during a recertification survey from 3/5/25 to 3/12/25, the facility did not ensure that 5 of 5 randomly selected Certified Nurse Aides (Certified Nurse Aides #17, 18, 19, 20 and 21) received at least 12 hours per year of in-service education. Specifically, Certified Nurse Aides #17, 18, 19, 20, and 21 received only 10 of the 12-hours mandatory in-service training.

Inspectors wroteBased on record review and interviews during the recertification survey conducted 03/05/25-03/12/25, the facility did not ensure each resident was offered pneumococcal immunizations and education regarding the benefits and potential side effects of the immunizations for 2 of 5 residents (Residents #1, #24) reviewed. Specifically, there was no documented evidence that Resident's #1 and #24 were offered, declined, or received education regarding the pneumococcal immunization.

Inspectors wroteBased on record review and interview conducted during recertification and abbreviated survey (NY00365960) from 03/05/2025 to 03/12/2025, the facility did not ensure that the resident's care plan was reviewed and revised timely for 1 of 2 residents (Resident #164) reviewed for falls. Specifically, Resident #164's care plan was not reviewed or updated to reflect new interventions after a medical assessment on 11/29/24 and a fall on 12/2/24.

Inspectors wroteBased on observation, record review, and interview conducted during the recertification and abbreviated survey (NY00365646) from 3/5/24 to 3/12/24, it was determined the facility did not ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #165) reviewed for accidents. Specifically, a two (2) person assist was not provided as per care plan resulting in Resident #165 rolling to the floor from the bed and sustaining a laceration/abrasion to their forehead, bridge of nose, and left hip.

Inspectors wroteBased on record review and interviews during an abbreviated survey (#NY00344591), the facility did not ensure the residents' right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed. This was evidence for 1 (Resident #1) of 3 reviewed. Specifically, the facility changed Resident #1's rooms without providing the residents with advanced written notification.

Inspectors wroteBased on observation, interview, and record review during an abbreviated survey (NY00335256) conducted on 4/5/24, the facility did not ensure the environment remained as free of accident hazards as possible for 1of 3 residents reviewed for accidents. Specifically, the certified nursing assistant providing caring to Resident #1 did not request the assistance of another staff member during transfers from the toilet to the wheelchair to ensure safety. Resident #1 fell to the floor. No injuries documented upon assessment post fall.

Inspectors wroteBased on observation, interviews and record review conducted during the recertification and abbreviated survey (00325156) from 1/28/24 to 2/2/24, the facility did not ensure that sufficient nursing staff was consistently provided to meet the needs of residents on all shifts. Specifically, 1) multiple residents reported during confidential interviews and the group meeting (Resident Council) a of lack of staff to respond to call bells and provide assistance with activities of daily living; 2) multiple nursing staff members reported a lack of sufficient staffing; and 3) analysis of the actual staffing schedule showed that on multiple occasions during the month of January 2024, the facility was below the minimum levels documented on the Facility Assessment.

Inspectors wroteBased on observations and interviews conducted during the recertification survey from 1/28/24-2/2/24, the facility did not ensure that food was stored, prepared, distributed, and served in accordance with professional standards for food service safety. [...]

Inspectors wroteBased on observation and staff interview during the recertification survey from 1/28/24 - 2/2/24, the facility did not ensure that garbage was contained and disposed of in an appropriate manner. Specifically, there was garbage on the ground surrounding the compactor, and the area was not maintained in a sanitary condition to prevent harborage and feeding of pest.

Inspectors wroteBased on record review and interview during the recertification survey from 1/28/24 to 2/2/24, the facility did not ensure that staff maintained an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1., The facility 'COVID positive resident line list' documented the date of the first COVID positive resident (Resident #100) inaccurately, and 2. Physician orders for transmission based precaution-contact/droplet precaution were not obtained timely for five residents (Resident #215, #216, #92, #218, #18) with 2/1/24 positive COVID test results.

Inspectors wroteBased on observation, interview, and record review during the recertification survey from 1/28/24 to 2/2/24, the facility did not ensure that care was provided in a manner that maintained dignity for 1 of 2 residents (Resident #78) reviewed for dignity. Specifically, Resident #78's urinary catheter drainage bag was not concealed to prevent direct observation by others.

Inspectors wroteBased on record review and interview during the recertification survey conducted from 1/28/24-2/2/24, the facility did not ensure they provided the appropriate liability and appeal notices to Medicare beneficiaries at the termination of Medicare coverage. This was evident for 3 (Resident #5, #64, #91) of 3 residents reviewed for beneficiary protection notification rights. Specifically, Resident #5 was discharged from the facility to home and did not receive a written Notice of Medicare Non-Coverage for Medicare Part A as required. And the facility was unable to provide documented evidence that Residents #64, and #91 or their representatives received the Notice of Medicare Non-Coverage for Medicare Part A at least two calendar days before Medicare covered services ended as required.

Inspectors wroteBased on record review and interviews during the recertification and abbreviated surveys (NY00299405, NY00332134, and NY00332265) from 1/28/24 to 2/2/24 the facility did not thoroughly investigate all allegation of abuse for 2 out of 3 residents (Resident #267 and Resident #273), reviewed for abuse. Specifically, on 1/24/24 the facility reported to the New York State Department of Health that Resident #273's family member threatened to call the New York State Department of Health to say Resident #273 was sexually assaulted, however on 1/25/24 the facility sent Resident #273 to the hospital for an allegation of sexual abuse and the facility did not notify the New York State Department of Health and did not complete a thorough investigation or suspend the accused during the investigation. [...]

Inspectors wroteBased on observation, interview, and record review during a Recertification survey from 1/28/24 to 2/2/24, the facility did not ensure the environment remained as free of accident hazards as possible for 1 (Resident #365) of 4 residents reviewed for accidents. Specifically, the cable wire in the Resident #365's room was not secured, encased, and out the resident walkway to prevent accidents.

Inspectors wroteBased on interview and record review during the recertification and abbreviated (NY00324842) surveys conducted 1/28/2024-2/2/2024, the facility did not ensure a resident was provided with adequate fluids to maintain proper hydration and health for 1 of 5 residents (Resident #272) reviewed for nutrition/hydration. Specifically, Resident #272, was not administered intravenous fluids as ordered.

Inspectors wroteBased on interviews and record review during the recertification and abbreviated surveys (NY00331117) from 1/28/24 to 2/2/24, the facility did not ensure that medical records were maintained, complete and accurately documented for each resident in accordance with accepted professional standards and practices. Specifically, nursing staff documented in the Treatment Administration Record on one occasion 'intact' and on three occasions 'skin intact' between two dates that the wound doctor had documented an open wound, and on one occasion on the same date the resident went for a consult to evaluate the open wound. This was evident for 1 of 8 residents (Resident # 269) reviewed for Pressure Ulcers. The finding is: Resident #269 was admitted with diagnoses including surgical wound post laminectomy, spinal stenosis, and vascular dementia. [...]

Inspectors wroteBased on interviews, and record review during an abbreviated survey (NY00324542), the facility failed to ensure that residents were free of significant medication errors for 2 of 5 residents (Resident #1 and Resident #2) reviewed for anti-seizure medications. Specifically, Resident #1 had a physician's order for Vimpat (controlled antiseizure medication) 200 milligrams (mg) 1 tab every 12 hours at 9AM and 9PM daily, and over three days in 08/2023 and four days in 09/2023. A total of 12 doses of Vimpat were not administered to Resident #1. Resident #2 had a physician's order for Keppra (anti-seizure medication) 1000 mg 1 tab every 12 hours at 9AM and 9PM daily, and over six dates a total of 7 doses of Keppra were not administered to Resident #2. Subsequently, Resident #1 suffered a seizure on 9/17/23 at 3:45 PM and was transferred to the hospital. [...]

Inspectors wroteBased on interviews and record review during an abbreviated survey (NY00324542), the facility did not provide pharmaceutical services, including procedures that assure accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 5 residents (Resident #1 and Resident #2) reviewed for pharmaceutical services. Specifically, Resident #1 had a physician's order for Vimpat (controlled antiseizure medication) 200 milligrams (mg) 1 tab every 12 hours at 9AM and 9PM daily, and over three days in 08/2023 and four days in 09/2023 a total of 12 doses of Vimpat were not administered to Resident #1. Resident #2 had a physician's order for Keppra (anti-seizure medication) 1000 mg 1 tab every 12 hours at 9AM and 9PM daily, and over six dates a total of 7 doses of Keppra were not administered to Resident #2. [...]

Inspectors wroteBased on observations, record reviews and interviews conducted during a Recertification Survey, it could not be ensured that the facility developed and/or followed a plan of care with measurable goals, timeframes and interventions for 2 of 6 residents (Residents #74 and #92) reviewed for Pressure Ulcers, 1 of 5 residents reviewed (Resident #89) for Unnecessary Medications and 1 of 1 resident (Resident #58) reviewed for Activities of Daily Living (ADLs). Specifically, 1) heel booties and/or offloading of feet was not provided for Resident #74, 2) heel booties were not applied for Resident #92, 3) care plans including diagnoses and medications were not developed for Resident #89, and 4) staff did not provide mouth cares as per the ADL plan of care for Resident #58.

Inspectors wroteBased on observation, interview and record review conducted during a recertification survey the facility did not ensure that 2 of 6 residents (#74 and #92) reviewed for pressure ulcer was provided the appropriate care to promote healing of an existing pressure ulcer. Specifically, for resident #74 [NAME] feet were not off loaded at all times as per physician order and heel float devices were not applied as per the plan of care and 2) for resident #92 heel booties were not applied as per physician orders.

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification Survey, it could not be ensured that the facility maintained infection prevention and control to provide a safe and sanitary environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, 1) for 1 of 1 resident (Resident #74) reviewed for Urinary Catheter, staff did not ensure a foley catheter bag and tubing were placed to prevent contamination, 2) laundry was not handled and transported to prevent contamination and 3) staff did not perform hand hygiene after contact with potentially contaminated surfaces.

Inspectors wroteBased on observations, record reviews and interviews conducted during the Recertification Survey, it could not be ensured that the facility provided necessary services to maintain good oral hygiene for 1 of 1 resident (Resident #58) reviewed for Oral Hygiene. Specifically, Resident #58 was observed to have substantial residue on her tongue during several observations. The finding is: 1. Review of Resident #58's 2/27/2020 MDS showed that Resident #58 was admitted on [DATE] with diagnoses including Gastric Hemorrhage, Ulcerative Colitis with Rectal Bleeding, Malnutrition and Other Artificial Openings of the Gastrointestinal Tract. The MDS also showed that Resident #58 was moderately cognitively impaired and required a gastrostomy tube to sustain life. Furthermore, the MDS showed that Resident #58 requires extensive assistance of 1 staff for eating and personal hygiene. [...]

Inspectors wroteBased on observations, record reviews and interviews during a Recertification Survey, it could not be ensured that the facility provided residents with a dignified dining experience. Specifically, staff were observed feeding residents while standing and the residents were seated. The finding is: Review of the facility Policy and Procedure revised on 1/6/2020 showed that the facility is committed to assuring the rights and protection of its residents to be treated with respect, dignity and self-determination. 1. Review of the 8/19/2020 Minimum Data Set (MDS; a resident assessment tool) showed that Resident #79 was admitted on [DATE] with diagnoses including Bipolar Disorder, Metabolic Encephalopathy and Chronic Kidney Disease. [...]

Inspectors wroteBased on observations, interviews and record reviews during the Recertification Survey, it could not be confirmed that the facility ensured that the call bell system was accessible for 4 of 8 residents reviewed for Environment. Specifically, the facility did not ensure that Residents #40, #46, #47 and #74 either had a call bell and/or that the residents' call bell was within reach.