Briarcliff Nursing and Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 6 residents (Resident #1) reviewed for accuracy and completeness of clinical records. The facility failed to ensure MA documented Resident #1's blood pressure on the eMAR when Resident #1's metoprolol (blood pressure medication) was held on July 4th of 2026. This failure could place residents at risk of not receiving proper care or having needs met due to inappropriate documentation.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 3 (Resident #1) residents reviewed for accuracy and completeness of clinical records. The facility failed to ensure LVN A accurately documented his findings on Resident #1's Initial Nursing Evaluation on 06/04/26. This failure could place residents at risk of a health decline.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure the resident had the right to personal privacy during medical treatment for 4 (Resident #156, Resident #52, Resident #71, and Resident #133) of 7 residents reviewed for resident rights. The facility failed to ensure MA A closed the door or the curtain during medication administration for (Resident #156, Resident #52, Resident #71, and Resident #133) on 05/12/2026. This failure could place residents at risk of not having their personal privacy maintained during medical treatment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program, to keep the facility free of pests for 2 (Resident #83 and Resident #57) of 8 residents reviewed for pests. The facility failed to ensure Resident #83 and Resident #57's room was free from roaches. This failure could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 8 residents (Residents #2) reviewed for dignity. The facility failed to ensure Resident #2 was provided oral care on a regular basis. This failure could place residents at risk for decreased quality of life, quality of care, and self-esteem.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 (Resident #28) of 8 residents reviewed for respect and dignity. The facility failed to get Residents #28's consent to search personal possessions, resulting in confiscating items without notice. This failure placed residents at risk of anxiety, frustration, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, including housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 residents (Resident #11) reviewed for resident rights. The facility did not ensure Resident #11's toilet was free from stains on 05/13/26. This failure could place residents at risk for an unsafe environment and unsanitary environment.

Inspectors wroteBased on interviews and record review, the facility failed to ensure an assessment accurately reflected the resident's status for 1 (Resident #84) of 8 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #84 MDS assessment was accurately coded for Hospice Care. This failure could place residents at risk for receiving inappropriate care due to an inaccurate assessment data not reflecting their actual status and needs. Findings Included: Record review of Resident #84's face sheet dated 05/13/2026 reflected the resident was a [AGE] year-old female who was admitted to the facility on [DATE]. Pertinent diagnoses included: Alzheimer's Disease, Type 2 Diabetes (high levels of sugar in blood), Hypertension (high blood pressure), Unspecified Dementia, Anxiety Disorder, Mood Disorders. [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) for 1 (200-hall binder) of 6 controlled medication binders reviewed for pharmacy services. The facility failed to ensure controlled medications were accurately accounted for when LVN Q failed to sign the narcotic medication count sheet during shift change on 05/12/2026. This failure could place residents receiving controlled medications at risk of medication discrepancies, diversion, medication errors, and lack of accountability for controlled substances. Findings Included: Record review of the 200-hall medication aide cart-controlled substance binder revealed LVN Q failed to sign the narcotic medication count sheet during shift change (2p.m-10p.m.) on 05/12/2026 at 3: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were secured and stored securely, maintained within their expiration dates, and labeled properly in accordance with currently accepted professional principles and standards for 1 of 2 medication carts (500 Hall Medication Cart) and 2 of 2 medication storage rooms (500 Hall Medication Storage Room and 600 Hall Medication Storage Room) reviewed for labeling and storage. The facility failed to dispose of a bottle of over the counter (OTC) anti-acid tablets from the 500 Hall Medication Cart which had an open date of 05/02/25. The facility failed to properly label a vial of lidocaine (local anesthetic medication used to induce temporary numbness or loss of feeling in specific skin areas) with an open or expiration date from the 500 Hall Medication Cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Residents #2 and #4) of 8 residents reviewed for infection control practices. The facility failed to ensure: CNA F and CNA G performed hand washing or change gloves during peri care on Resident #2. -oxygen tubing and humidifier bottle was labeled, dated, in a protective sheath, and kept off the floor for Resident #2. -foley bags were kept off the floor for Resident #2 and Resident #4. These failures could place residents at risk of exposure and/or possible transmission of communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to formulate an advance directive for 1 (Resident #1) of 6 residents reviewed for Advance Directives. The facility failed to ensure Resident #1's OOH-DNR was completed. The OOH-DNR form did not have the physician's signature. This failure could affect all residents who have implemented Advance Directives and established their choice not to be resuscitated at risk of receiving CPR against their wishes.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents were free from chemical restraints not required to treat the resident's medical symptoms for 2 (Resident #2 and Resident #3) of 6 residents reviewed for unnecessary medications. 1. The facility failed to have an adequate indication for the use of the medication Lurasidone (an antipsychotic) for Resident #2 before administering the medication with a black box warning. 2. The facility failed to have an adequate indication for the use of the medication Haldol (an antipsychotic) and Seroquel (an antipsychotic) for Resident #3 before administering the medication with a black box warning. This failure could put residents at risk of harm from adverse reactions or harmful side effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for five residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 10 residents reviewed for abuse. Resident #2 sustained facial injuries from an altercation with resident #4 on 05/27/25 7:59 PM as they passed each other in the 600 hall. Resident #3 sustained facial injuries from being hit in the face by Resident #2 on 05/19/25 @1:30 PM in Resident #3's room. \Resident #5 was slapped in the face by Resident #6 as she was trying to get by Resident #6. Resident #6 was scratched by resident #5 in retaliation for being slapped in the face by Resident #5 on 06/19/25 @4:39 PM. These failures have the potential to result in serious injury.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation were reported immediately, but not later than two hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials, including to the State Agency, in accordance with State Law through established procedures for 2 out of 10 residents (Resident #1 and Resident #2) reviewed for reporting of abuse/neglect. 1. The facility failed to report to the local law enforcement agency a resident-to-resident physical altercation involving Resident #2 and Resident #4 resulting in minor injuries that occurred on 05/27/25. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a care plan to include Resident #1's behaviors and interventions. This failure could place residents at risk of not receiving safe and appropriate care.

Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure the residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 10 residents (Resident #101) reviewed for abuse. The facility failed to ensure Resident #101 was free from abuse. CNA H slapped Resident #101 on the face on 8/1/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 08/01/24 and ended on 08/01/24. The facility had corrected the noncompliance before the survey began. The facility was informed about the past non-compliance on 3/26/2025 at 12:32pm. This failure affected one resident and placed additional 9 residents who were on the memory unit at risk of abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 residents out of 6 (Resident #119, Resident #124, and Resident #205) and 1 shower bed (hall 300) out of 4 that were reviewed for safe environment. 1. The facility failed to ensure bathroom sinks' hot water temperatures were below 110 degrees Fahrenheit in occupied rooms for Resident #119, Resident #124, and Resident #205. 2. The facility failed to ensure the shower bed in Hall 300 shower room was in good condition. These failures could affect residents by placing them at risk for diminished quality of life due to the lack of a well-kept environment and water temperatures over 110 degrees Fahrenheit, placing residents at risk of being in an unsafe environment and at risk for burn injuries. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial need that were identified in the comprehensive assessment for 2 of 10 residents (Resident #101 and Resident #82) reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a comprehensive person-centered care plan for Resident #101 to address assist feeding. 2. The facility failed to develop a comprehensive person-centered care plan for Resident #82 to address identifiable triggers to his active diagnosis of Post Traumatic Stress Disorder. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 8 residents (Resident #13) reviewed for accidents and hazards: The facility failed to ensure Resident #13 did not have disposable razors in his room. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 18 (Resident #39) residents reviewed for respiratory care. The facility failed to ensure Resident #39 had an oxygen sign posted on their door to alert everyone that he was on oxygen. This deficient practice could place residents who receive respiratory care at risk for developing respiratory complications, make others unaware oxygen was in use, and of receiving inappropriate and inadequate care.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain 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 for 2 (Resident #66 and Resident #145) of 8 residents observed for infection control. 1. LVN F failed to sanitize hands before administering G-tube medications to Resident #66. 2. CNA O did not remove their contaminated gloves after catheter care prior to cleansing Resident #145 of bowel movement. CNA O proceeded to clean without performing hand hygiene and maintained usage of dirty gloves while cleaning posterior area and used the same gloves to apply a clean brief. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents (Resident #5) reviewed for abuse. 1)The facility failed to ensure CNA F communicated Resident #5's allegation of abuse on 11/17/24. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 11/20/24 and ended on 11/20/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from verbal abuse for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to prevent CNA A, from verbally abusing Resident #1 on 04/29/24 when she referred to her as ay mi pendejita [NAME], [NAME] estas (hello my stupid pretty, how are you). This failure could place residents at risk of emotional distress, fear, decreased quality of life and further abuse. Record review of Resident #1's admission record dated 01/29/25 reflected a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #4 and Resident #6) of 11 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #4 was coded in the MDS for a fall on 2/28/24. 2. The facility failed to accurately identify Resident #6's unstageable pressure ulcer on her Discharge Return Anticipated MDS Assessment on 01/30/24. This failure could place residents at risk of receiving inadequate care and services based on inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 4 residents (Resident #2 and Resident #3) reviewed for respiratory care. The facility failed to ensure Resident #2's and Resident #3's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 4 Residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to ensure LVN A accurately documented that Resident #1 was currently on an anti-coagulant. 2. The facility failed to ensure LVN A accurately documented neurological check findings for Resident #1 post fall. These failures could place residents at risk of not receiving appropriate care resulting in deterioration in condition, exacerbation of disease process, overmedication, and increased risk of harm or injury.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 3 of 10 residents (Resident #2, Resident #3, Resident #10) reviewed for care plans. The facility failed to ensure Resident #2, Resident #3, and Resident #10's care plans reflected the risk of elopement/wandering and their placement in the secure unit. This failure could place residents at risk of not receiving the care and services as indicated in the comprehensive care plans.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for pest control. The facility failed to ensure the current pest control program was effective to eradicate and contain common household pests including roaches in multiple areas including resident rooms, hallways, and dining room. This failure could place all residents at risk of insect borne illnesses, to live in an uncomfortable/non-homelike environment free of pests, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide foot care and treatmenet to maintain mobility and good foot health for 1 (Resident #2) of 1 residents reviewed for foot care services. The facility failed to ensure Resident #2 received podiatry services as Resident #2's toenails were long (about an inch overgrown), not trimmed, and Resident #2 was not treated by the in-house podiatrist during their last visits. This failure could place residents at risk of potential negative outcomes related to foot health including pain, discomfort, poor foot hygiene, or a decline in residents' physical condition.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided with professional standards of practice for 1 of 4 residents (expired Resident #1) reviewed for oxygen in that: LVN A failed to document baseline pulse, respiratory rate, O2 saturation, and lung sounds before and after a nebulizer treatment for Resident #1. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased qualify of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from abuse for 1 of 32 residents (Resident #87) reviewed for abuse, in that: 1. The facility did not take measures to prevent verbal abuse of Resident #87 by LVN C. 2. The facility failed to implement measures, like identifying verbal abuse and handling residents with behaviors r/t PTSD, to protect residents from further abuse. 3. The facility failed to protect Resident #87 from having his mustache shaved against his will. 4. The facility failed to prevent LVN C from instructing staff to not give Resident #87 a blanket when Resident #87 complained of being cold. 5. The faciity failed to follow Resident #87's care plan in giving him fluids to prevent dehydration. 6. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 9 residents (Resident #61) reviewed for treatment and care for diabetic assessments and supports, in that: The facility failed to identify care or support for Resident #61 needs for an insulin [a hormone that lowers the level of glucose (a type of sugar) in the blood] delivery pump, blood glucose [sugar] monitor, remote controller and lab assessments for HbA1C [ an average blood glucose (sugar) levels for the last two to three months]. Resident #61 was admitted on [DATE] with an insulin pump. The pump was designed only to be used with 100-units per milliliter insulin and was used with 200-units per milliliter insulin. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to keep information that is resident-identifiable from the public for all of the residents of the facility, in accordance with professional standards and practices, in that: The facility failed to prevent having identifiable resident information on top of a counter in the dining room, unattended. These deficient practices could affect all residents whose records are maintained by the facility and could place them at risk for violation of privacy.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 4 of 32 residents (Residents #5, #15, #67, and #144) reviewed for advanced directives, in that: 1. Resident #5's OOH-DNR was missing the physician's license number. 2. Resident #15's OOH-DNR was missing the witness signatures. 3. Resident #67's OOH-DNR was missing the executor's signature. 4. Resident #144's OOH-DNR was witnessed two department heads, one of whom provided direct care. These failures could place residents at-risk for residents' rights not being honored and having CPR performed against the residents' will.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the resident's goals and preferences, for 1 of 2 residents (Resident #20) reviewed for respiratory care in that: The facility failed to monitor Resident #20's oxygen therapy by failing to monitor oxygen saturation levels to monitor the resident's respiratory condition and response to therapy provided. This failure could affect residents who were dependent on respiratory care and could contribute to upper respiratory infections and worsening of their physical condition.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure Residents are free of any significant medication errors, for 1 of 8 residents (Residents #87) reviewed for significant medication errors, in that: 1. Resident #87 was administered clonazepam 1mg without a physician's order by LVN G 77 times from 07/25/2023 to 12/19/2023. These failures placed residents at risk for receiving medications not prescribed by a physician.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. In the reach-in refrigerator, there was/were: a. A head of lettuce in a plastic bag, undated. b. A container wrapped in foil with P labeled on top instead of fortified pudding with no use-by date. c. Overcrowding of boxes on the top rack. These boxes were less than 6 inches away from the ceiling. d. Sandwiches wrapped in plastic that did not have a use-by date. e. A container of pickles with circles of black substances on top of the container f. A container that was labeled FP and not fortified pudding with no use-by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 Bistro refrigerators reviewed for food safety, in that: The facility failed to ensure that the Bistro refrigerator had a temperature log attached to the refrigerator and the contents of refrigerator were labeled with date and name of the food product. This failure could place residents at risk for food borne illnesses and at risk for choking.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain 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 for 4 of 7 residents (Resident #35, #42, #97 and #82) observed for infection control in that: 1. During the medication pass, LVN K did not sanitize the wrist blood pressure cuff used between Resident #35 and Resident #42. 2. During the medication pass, CMA L did not sanitize the wrist blood pressure cuff used between Resident #97 and Resident #82. These deficient practices could place residents at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 4 shower rooms (Shower room [ROOM NUMBER]), in that: Observation on 12/17/2023 at 10:42 a.m. in Shower room [ROOM NUMBER], next to resident room [ROOM NUMBER], revealed approximately six razors were found on top of a storage bin and within reach of residents. Additionally, the toilet located inside the shower room was loosely affixed to the wall and the toilet room had a foul odor resembling sewer gas. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to support resident rights to voice grievances to the facility or other agency or entity that hears grievances for 1 of 29 residents (Resident #80) and the months reviewed (October, November, and December 2023) reviewed for grievances, in that; LVN P did not initiate a grievance report on behalf of Resident #80 when Resident #80 reported mistreatment by CNA D. This failure placed residents at risk by denying their right to make and have grievances heard and contributed to feelings of not being heard and unresolved issues.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents' mental, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 32 residents (Resident #87) reviewed for care plans in that: The facility failed to implement Resident #87's comprehensive person-centered care plan to address dehydration and ADL self-care performance deficit related to eating. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, and described in the plan of care for 1 of 7 residents (Resident #35) reviewed for nursing competencies, in that: LVN K failed to administer Resident #35's blood pressure medication within the acceptable parameters for safe medication administration and did not obtain/document Resident #20's oxygen saturation readings prior to administering oxygen per the physician's orders. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 7 Medication Carts (600 Hall Medication Cart) reviewed for storage of drugs, in that: The 600 Hall Medication Cart was left unlocked and unattended with the cart keys attached to the lock. This failure could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care. Facility staff transferred Resident #2 three times after a fall before getting her in bed. Resident #2 was in pain before the transfers. Later x-rays showed resident had sustained a fractured hip. This failure placed resident in unnecessary pain and discomfort with a potential for further injury.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan within seven days after completion of the comprehensive assessment, for 1 of 8 residents reviewed for care plans. (Resident #1) The facility did not develop and implement a comprehensive care plan when Resident #1 was discovered with a fracture to the base of the left 5th proximal phalanx. July 26,2023 and was not addressed until September 19,2023. This deficient practice could affect residents with a status change at risk for not receiving the necessary care in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure staff verified equipment was secure before initiating a transfer. CNA E and G did not verify Resident #1 bed wheels were locked before initiating a transfer leading to Resident #1 losing balance and falling back into bed. This deficient practice could place the residents at risk for harm, serious injury or death.