Briarcliff Skilled Nursing Facility

Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #2, Resident #3, Resident #10 and Resident #30) of 18 residents reviewed for care plans. 1. The facility failed to ensure Resident #2 had a comprehensive care plan for hospice services. 2. The facility failed to ensure Resident #3 had a comprehensive care plan for PTSD. 3. The facility failed to ensure Resident #10 had a comprehensive care plan for dialysis services. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 2 of 18 residents (Resident #2 and Resident #62) reviewed for resident rights. 1. The facility did not ensure Resident #2 was invited to participate in the quarterly care plan meetings. 2. The facility did not ensure Resident #62's family member was invited to participate in his quarterly care plan meetings. This failure could place residents at risk of not having individual needs met by depriving them of the opportunity to participate in the decision making regarding their care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 18 residents reviewed for resident rights. (Resident #32)1. The facility failed to repair damage to the inside door of the bathroom door, and clean black marks from the bathroom door and wall near the bathroom entrance in Resident #32's room. 2. The facility failed to clean the windows in Resident #32's room as she requested. These failures placed residents at risk of an uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 1 of 18 residents (Resident #30) reviewed for restraint use. The facility failed to ensure Resident #30 remained free from physical restraints when her wrists were restrained by CNA A while providing care on 03/16/26. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the baseline care plan was developed and implemented for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 2 of 7 (Resident #2 and Resident #71) reviewed for comprehensive resident centered care plans. 1. The facility did not ensure Resident #71's baseline care plan addressed the care of a condom catheter. 2. The facility did not ensure a RN was part of Resident #2 and Resident #71's baseline care plan process, that included the instructions for resident care needed to provide effective and person-centered care. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 18 residents reviewed for ADLs. (Resident #44)The facility failed to ensure Resident #44 was clean shaven as was his preference. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs, which could result in poor care, feelings of poor self-esteem, and lack of dignity and health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained free from accidents, hazards, and each resident received adequate supervision and assistance while providing care for 3 of 8 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents and supervision. 1. The facility failed to supervise Resident #2 from assaulting Resident #3 when CNA D left the memory care unit to get additional staff to assist with Resident #2 on 08/27/25. Resident #3 suffered bruising to her face and forearm. 2. The facility failed to provide sufficient supervision on the secured unit to provide timely assistance to Resident #1 after he fell. Resident #1 fell at midnight on 06/21/25 and remained on the floor until 4:58AM. He sustained bruising to his left side area. This deficient practice was identified as past non-compliance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an environment that was free of accident hazards for 1 of 22 residents reviewed for accident hazards. (Resident #3) 1. The facility failed to ensure coffee was served at a safe temperature for Resident #3 resulting in Resident #3 obtaining 2nd degree burns to her right and left upper thigh and groin areas. 2. The facility failed to implement measures to prevent other coffee spills with burns. 3. The facility failed to monitor the temperatures of hot liquids served to residents. 4. The facility failed to identify residents at risk for coffee burns. 5. The facility failed to ensure coffee temperatures were at an appropriate safe temperature prior to serving to residents. An Immediate Jeopardy (IJ) was identified on 1/28/25. The IJ Template was provided to the facility on 1/28/25 at 11:54 AM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety requirements. 1. The facility failed to ensure there was minimal carbon buildup on approximately 6 baking sheet pans. 2. The facility failed to ensure the stove was clean from debris and black carbon buildup on the stove top. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in a locked compartments, under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 8 residents (Resident #30) and 2 of 6 medication carts (Hall A nurse's cart and Hall B nurse's cart) reviewed for medication storage. 1. The facility failed to ensure Resident #30 did not have medications stored in her room. 2. The facility failed to ensure the Hall A nurse's cart was secured and unable to be accessed by unauthorized personnel on 01/27/25. 3. The facility failed to ensure LVN M secured Hall B nurse's cart when she left it unattended on 01/28/25. These failures could place residents at risk for not receiving drugs and biologicals as needed and drug diversions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and at a safe and appetizing temperature for 4 of 22 residents (Resident #1, Resident #57, Resident #58, and Resident #64) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature for Resident #1, Resident #57, Resident #58 and Resident #64. This failure could place residents at risk for weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and 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 7 of 8 residents (Residents #2, #5, #14, #31, #55, #62 and #74) reviewed for infection control practices. 1. LVN G failed to remove her dirty gloves and perform hand hygiene during Resident #55's wound care. 2. The facility failed to ensure the proper disinfectant cleaner was used to clean Resident #62's isolation room with clostridium difficile (bacteria that causes infection in the large intestine). 3. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 1 of 2 residents reviewed for restraint use (Resident #5). The facility failed to ensure Resident #5 was free from physical restraints in the form of a lap harness on a broda chair (a broda chair is a chair or wheelchair that provides comfort, support and mobility throughout the day). The facility failed to ensure Resident #5's restraint was accurately assessed, monitored, documentation of ongoing re-evaluation of the need for the restraint and provided a physician order for the lap harness. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 22 residents (Resident #2 and Resident #5) reviewed for MDS assessment accuracy. 1. The facility failed to accurately reflect Resident #2's safety vest (trunk harness) or lap belt as a restraint on her quarterly MDS assessment dated [DATE]. 2. The facility failed to ensure Resident #5's restraint was accurately coded on her quarterly MDS assessment dated [DATE]. These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 2 residents reviewed for respiratory care (Resident #30) The facility failed to administer Resident #30's oxygen as ordered by the physician. This failure could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision to prevent avoidable accidents for 4 of 17 residents reviewed for accidents. (Residents #52, Resident #23, Resident #17, and Resident #54) The facility failed to ensure the ice machine was always locked to prevent Residents #52 and #23 from getting ice themselves. The facility failed to ensure Resident #17, and Resident #54 had adequate supervision after a resident-to-resident altercation. The facility failed to ensure Resident #54 did not have cleaning supplies in his room. These failures could place residents at risk of injury from accident and hazards.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 21.43%, based on 6 errors out of 28 opportunities, which involved 1 of 7 residents (Resident #30) reviewed for medication administration. 1. RN A administered Brimonidine 0.2% eye drop (is used alone or together with other medicines to lower pressure inside the eye that is caused by open-angle glaucoma or ocular (eye) hypertension) in the right eye instead of the left eye as ordered on 12/12/23 for Resident #30. 2. RN A administered Moxifloxacin HCL eye drop (is an antibiotic that is used to treat bacterial infections of the eye) in the right eye instead of the left eye as ordered on 12/12/23 for Resident #30. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 17 resident reviewed for assessments. (Resident #37) The facility coded Resident #37's use of Aspirin (is used to treat pain and reduce fever or inflammation) as an anticoagulant (are medicines that help prevent blood clots) not an antiplatelet (are medications that prevent blood clots from forming. They work by stopping your platelets from sticking together) on his MDS. This failure could place residents at risk of not having individual needs met.

Inspectors wroteBased on record review, and interviews, the facility failed to ensure residents diagnosed as having a mental illness were screened and evaluated prior to admission by the local authority and receive care and services in the most integrated setting appropriate to their needs for 1 of 4 residents reviewed for PASRR screening. (Resident #26). The facility failed to correctly screen on admission, and refer, Resident #26 who was diagnosed with mental illness to the appropriate state designated mental health or ID authority for evaluation. This failure placed 1 resident at risk and could affect other residents with psychiatric diagnoses for not being assessed by the local authority and not receiving services to prevent declines.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 17 residents reviewed for care plans. (Resident #17) The facility failed to develop a care plan intervention of appropriate footwear for Resident #17, after her fall on 11/09/23. The facility failed to implement Resident #17's fall intervention to use of a walker after her fall on 11/09/23. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 4 resident (Resident #30) reviewed for hydration. The facility failed to ensure Resident #30 received adequate hydration. These failures could place residents at risk for dehydration, electrolyte imbalance, and infections.

Inspectors wroteBased on interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 24 residents reviewed for pharmacy services. (Resident #30) The facility failed to obtain medication from the pharmacy ordered after a hospitalization for Resident #30. This failure could place residents at risk for inaccurate drug administration and cause Resident #30 weight loss and possible rehospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and PRN orders for psychotropic drugs were limited to 14 days for 2 of 5 residents (Resident #17 and Resident #44) reviewed for unnecessary psychotropic medications. The facility failed to provide an appropriate diagnosis for Resident #17's use of Mirtazapine (is used to treat depression). The facility failed to have an appropriate diagnosis for Resident #44's use of Risperidone (is a type of antipsychotic medication that treats mental health conditions schizophrenia, bipolar disorder, and some symptoms of autism). [...]

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 2 of 17 residents reviewed for infection control. (Resident #52, Resident #23) The facility failed to lock the ice machine when not in use by staff, leaving it accessible to residents. This failure placed residents at risk for cross contamination and infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all patient care equipment was in safe operating condition for 1 of 2 resident (Resident#37) reviewed for safe, functional equipment. The facility failed to ensure Resident #37's wheelchair left armrest had padding. This failure could place residents at risk for skin issues and discomfort.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, and misappropriation of resident property and establish policies and procedures to report and investigate such allegations, for 1 of 5 staff (LVN A) reviewed for abuse/neglect. The facility failed to intervene when LVN A exhibited signs of impairment, admitted to being impaired, and was allowed to work her scheduled shift. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 2 of 27 residents (Resident #3 and Resident #13) and reviewed for pharmacy services. The facility failed to ensure Resident #3 took his medication on 10/17/23 resulting in Resident #3 selling his Hydrocodone to the Housekeeper. This did not result in any outcome for Resident #3. The facility did not ensure medications were properly administered to Resident #13 on 7/1/23. The ADON was not able to identify what medications had been administered to resident #13 on 2 separate occasions 21 minutes apart. This did not result in any outcome for Resident #13. [...]