McCrite Plaza at Briarcliff Skilled Facility

Inspectors wroteBased on observation and interview, the facility failed to prepare and serve food in accordance with professional standards for food service safety when facility staff failed to maintain sanitary conditions during food preparation and failed to label and properly store food items. This affected all residents in the facility. The facility census was 44. Review of facility policy, Handling Leftover Food, dated 1/21/26, showed:- Leftover foods will be properly handled, cooled, and stored to ensure food safety minimal waste.- Leftover foods stored in the refrigerator shall be wrapped, dated, labeled with an open date/or use by date that is no more than 72 hours from the time of the first use. - Refrigerated leftovers stored beyond 72 hours shall be discarded. Some food items will be stored for more than 72 hours (refer to Safe Food Storage: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat residents with consideration, respect, and full recognition of their dignity and individuality when staff brought three sampled residents (Resident #40, #23 and #21) to meals in the dining room on three consecutive days with uncombed and disheveled hair, and when staff brought Resident #40 to a concert in the facility lobby with disheveled hair and stains on his/her shirt. This affected three of 12 sampled residents (Resident #40, #23 and #21 ). The facility census was 46. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the timeliness development and revision of each resident's person-centered, comprehensive care plan when the facility failed to add oxygen use and include a physician ordered hand splint and failed to update discharge planning after discharge plans changed for one resident( Resident #45); when the facility failed to ensure a care conference was held each quarter for two residents (Resident #34 & #5); when the facility failed to include respiratory status of a resident diagnosed with pneumonia (an infection in the lungs that makes breathing difficult) for one resident (Resident #34) and additionally when the facility failed to update the continence status and goals putting the resident at higher risk for complications for one resident (Resident #5). This affected three of 14 sampled residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility staff failed to follow professional standards of care according to clinical standards for two residents who were admitted as high risk for skin injury (Resident #4 and Resident #3); when the facility failed to obtain treatment orders and apply interventions to reduce risk for skin injuries; when they did not have preventative measures put into place to reduce skin injury; when the care plan was not updated to reflect the needs of these two residents and additionally when the facility failed to properly set-up, maintain and ensure correct functioning of specialty equipment used to reduce the risk of skin breakdown (Resident #5 and Resident #8). This affected four residents of the 12 sampled. The facility census was 44. Review of facility's undated Activities of daily living and skin care policies showed: [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to prevent pressure ulcers and provide necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing and affecting two residents (Resident #4 and Resident #3) out of 12 sampled residents. The facility census was 47. Review of the facility's undated Skin Care Protocol policy showed:-Facility clinical staff will ensure residents who enter the facility without a pressure sore(s) will not develop pressure sore(s) unless a resident's clinical condition demonstrates that the condition is unavoidable. - Upon admission all residents will have a Braden Pressure Risk Assessment (a widely used, evidence-based tool designed to predict a patient's risk of developing pressure injuries/sores) completed by nursing staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper storage and labeling of medications and biologicals when the facility had an open bottle of lorazepam (an anti-anxiety medication) with no open date for one resident (Resident #45); opened multi-use vials of eye drops with no open date for two residents (Resident #6, #36), opened and un-dated multi-use bottles of nose spray for two residents (Resident #6 & discharged resident #52), un-dated multi-dose vial of ear drops (Resident #21), and additionally when the facility had two opened, un-dated glucose control solution (solution used for daily calibration/testing of bedside blood glucose machines). This affected five of 14 sampled residents. The facility census was 44. [...]

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 when the facility failed to ensure staff wore appropriate protective equipment when providing care to residents that required enhanced barrier precautions (EBP) to prevent transmission of diseases and infections to residents that are at a higher risk for infection for two residents (Resident #8, #20); failed to keep a catheter drainage bag off of the floor for one resident (Resident #13);failed to change gloves during cares between clean and dirty tasks (Resident #4) and additionally when the facility staff failed to follow handwashing requirements when serving residents in the dining room. This affected four of 12 sampled residents. The facility census was 44. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received an accurate assessment, reflective of the resident's status when the facility submitted an assessment with inaccurate information on how resident expelled urine from the body (Resident #8). This affected how the care plan was developed and implemented for one of 12 sampled residents. The facility census was 44. [...]

Inspectors wroteBased on interview and record review, the facility failed to prevent an avoidable medication error which resulted in the hospitalization of one resident (Resident #1) when facility staff administered insulin to a resident who was not a diabetic. The resident was admitted to the hospital with a diagnosis of hypoglycemia (low blood sugar; a direct effect of insulin administration) and received D10 (intravenous fluids with added dextrose). The resident was diagnosed with acute metabolic encephalopathy (a reversible brain dysfunction caused by a metabolic imbalance or toxicity) due to accidental insulin administration. This affected one resident out of two sampled. The facility census was 47. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to safely transfer one of two sampled residents (Resident #1) when staff were not aware the resident required transfer with a mechanical lift and a staff member transferred the resident with a gait belt. This affected one resident out of two sampled. The facility census was 47. [...]

Inspectors wroteBased on interview and record review, facility staff failed to follow facility policy by not securing one resident's (Resident #1) controlled substance (substances with high probability for physical and/or psychological dependence), resulting in the loss of the controlled substance. The facility census was 44. On 12/2/25, the Administrator was notified of the past noncompliance incident which occurred on 10/27/2025. On 10/28/25, facility administration was notified of the incident, an investigation immediately began and corrective actions were implemented to include: Replacement of the medication and education of all licensed staff regarding signing in and securing delivery of narcotic mediation. The noncompliance was corrected on 11/5/2025. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that one resident (Resident #1) received treatment and quality of care in accordance with professional standards of practice when Licensed Practical Nurse (LPN) A transcribed Resident #2's medications into Resident #1's Medication Administration Record (MAR) in error, which resulted in Resident #1 receiving 42 doses of the wrong medications and Resident #1 being admitted to the hospital with increased heart rate and low blood pressure. The facility census was 41. Review of the facility's undated Physician Orders for Medications and Treatments policy showed all medications will be administered as ordered by a healthcare professional. Review of the facility's undated Medication Administration Policy showed all medications will be administered to every resident in a safe manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to respect one resident's rights, when the facility performed Cardiopulmonary Resuscitation on Resident #1, when he/she had a signed Do Not Resuscitate order. This deficient practice affected one of four sampled residents. The facility census was 54. Review of the facility's, undated, Resident Rights Policy showed:- Each resident residing in the facility has the right and will be afforded the right to a dignified existence and self determination;-Each resident will have autonomy and choice to the maximum extent possible;-Resident rights include the right to request, refuse and/or discontinue treatment; -The right to end of life care that respect and follows the resident's stated goals and choices for care and service at the end of the resident's life. Review of Resident #1's admission Minimum Data Set (MDS: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare and serve food in accordance with professional standards of food service safety when staff failed to date the receipt of incoming products in the dry storeroom, label and date used products in the freezer and refrigerator, label and date leftovers in the refrigerator, discard expired leftovers, and monitor refrigerator, freezer and dishwasher temperatures on a daily basis. This had the potential to impact all residents by placing them at risk for food born illnesses. The facility census was 40. Review of the facility's policy Dietary Procedures, undated, showed the evening staff members will check the dates on containers of leftovers and dispose of food found to have been refrigerated for more than four days; A policy on temperature checks in the kitchen was requested and not provided; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure an invoked (activated by verifying incapacity of the resident to make decisions) Durable Power of Attorney (DPOA) was in place prior to allowing the designated agent to sign Outside of Hospital Do Not Resuscitate (OHDNR, it instructs health care providers not to begin cardiopulmonary resuscitation, or CPR, if the resident's breathing stops or if a resident's heart stops beating) forms which affected two of the 12 sampled residents, (Resident #22 and #18). Additionally they facility failed to ensure Resident #295's code status matched his/her's care plan. The facility census was 40. Review of the facility's undated policy for advance directives, showed: [...]

Inspectors wroteBased on observation and interviews, the facility failed to maintain a clean, comfortable, and homelike environment when the facility failed to maintain and replace holes in carpet, vacuum and sweep floors, clean stained furniture, repair scraped and missing paint from walls, clean and maintain food and medication carts, replace stained ceiling tiles, and clean facility windows. The facility census was 40. Review of facility policy, Cleaning and Infection Control of Non-Critical, Reusable Resident Care Equipment, undated, showed: -Cleaning-the physical removal of foreign material, e.g. dust, oil, organic material such as blood, secretions, excretions, and micro-organisms -Cleaning reduces or eliminates the reservoirs of potential pathogenic organisms -Cleaning is accomplished with water, detergents/sanitizers, and mechanical action; [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a criminal background check for for five of 10 sampled employees prior to employment start date and evaluate for history of abuse, neglect, exploitation, or misappropriation of resident property in order to prohibit and prevent such abuse, consistent with the applicable requirements at subsection §483.12(a)(3). The facility census was 40. The facility's Abuse, Neglect, and Exploitation Policy stated: - [NAME] Plaza at Briarcliff has developed and implemented this policy and procedure to prohibit abuse, neglect, exploitation, or misappropriation of property by any perpetrator including but not exclusive to any staff member or volunteer of this facility or any contracted agency staff, vendors, another resident, family member, or visitors of the resident or other residents. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide services that met professional standards of quality when staff failed to recognize and report significant weight loss and/or gain. This affected four of the 12 sampled residents (Resident #28, Resident #295, Resident #244, and Resident #294). Facility census was 40. The facility's policy for Monitoring Weights stated: -All residents will be evaluated for weight stabilization and timely identification of weight loss. -Significant weight loss will be defined as: 3% loss in one week, 5% loss in 30 days, 7.5% loss in 90 days, and/or 10% loss in 180 days. -The physician, resident, and/or legal representative will be notified immediately (within 24 hours) of any resident meeting the definition of significant weight loss in this policy and informed on the interventions implemented. [...]

Inspectors wrote3. Review of Resident' #22's Quarterly MDS, dated [DATE] showed: - Long and short term memory problems; - Lower extremities impaired on both sides; - Dependent on the assistance of staff for toilet use, showers, dressing, personal hygiene and transfers; - Had a urinary catheter (sterile tube inserted into the bladder to drain urine); - Always incontinent of bowel; - Diagnoses included obstructive uropathy ( a condition in which the flow of urine is blocked), Parkinson's disease (a disorder of the central nervous system that affects movement, often including tremors), progressive neurological disorder (condition where there is a progressive deterioration in functioning), Alzheimer's disease (a brain disorder that slowly destroys memory and thinking skills, and eventually, the ability to carry out the simplest tasks) and dementia (inability to think). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff used proper techniques when transferring four of the 12 sampled residents, ( Resident #18, #27, #28, and #14) during the use of a mechanical lift, and additionally during the use of a gait belt transfer for resident #28. The facility census was 40. Review of the facility's undated Use of Transfer Gait Belt policy showed: - Gait belts will be used when transferring residents who are partially dependent and have some weight bearing capacity; - Explain the procedure to the resident and place the gate belt around the resident's waist; - Ensure the belt is securely fastened and cannot be easily undone; - Staff members need to position one hand on either side of the gate belt with underhand grip and assist the resident forward. Review of the facility's undated Transfer and Repositioning policy showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff provided proper respiratory care when staff failed to date when oxygen tubing and water humidification bottles were exchanged out, and oxygen filters where changed (Resident #244, #28 and #11). This affected three of the 12 sampled residents. The facility census was 40. Review of the facility's Cleaning and Infection Control of Non-Critical, Reusable Resident Care Equipment policy, undated, showed: - Non-Critical Equipment are those items that either touch only intact skin but not mucous membranes or do not directly touch the elder; - Reusable Equipment is a device designed and tested by the manufacturer, that is suitable for reprocessing prior to use on a elder; - All equipment must be cleaned immediately if visibly soiled; Review of the facility's Oxygen Administration policy, undated, showed: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff administered medications with a medication rate of less than five percent when facility staff made two medication errors out of 25 opportunities for error resulting in a medication error rate of eight percent which affected two of the 12 sampled residents (Resident #19 and #16). The facility census was 40. Review of the facility's undated policy for medication administration showed, all medications will be administered to every resident by a licensed nurse or a Certified Medication Technician (CMT) and as ordered by a physician in a safe and sanitary manner. The facility did not provide a policy for administration of eye drops. Review of the website, https://webmd.com, for refresh eye drops showed: - To avoid contamination, do not touch the dropper tip to the eye or or any other surface; [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store and label drugs and biological's in accordance with current accepted professional principles for three (Resident #12, #28, and #193 ) out of the 12 sampled residents when the facility failed to store medications in a locked storage area for Resident #28 and Resident #193. Additionally, the facilty failed to supervise Resident #12 while taking medications. The facility census was 40. Review of facility policy, right to self-administer medications, undated, showed: -A resident may self-administer medications only if approved in writing by the resident's physician and a licensed nurse has determined that the resident can perform the task safely and accurately. -A licensed nurse will assess the resident to determine the resident's ability to self-administer their medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a means of directly contacting caregivers when staff failed to identify and correct bathroom call light pull cords that had been wrapped around the handrail on the wall, leaving them inoperable and inaccessible to residents. The facility census was 40. The facility's Call Light, Bed Alarm System policy showed: -Call lights are to be present in all resident rooms and bathrooms. -The policy fails to address the issue of call lights being operable and accessible to a resident lying on the floor in need of help. The facility's Accident Prevention policy showed all staff members will ensure that each resident's environment remains as free from accident hazards as possible. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure staff provided quality of care and treatment in accordance with professional standards of practice when staff failed to reposition one resident and additionally failed to follow physician's orders for this resident to be laid down after lunch (Resident #14's ). This affected one resident out of twelve sampled residents. The facility census was 40. Review of facility policy, Safe Lift, Transfer, and Repositioning Policy, undated, showed: -Transfer and mobility assistance as well as other resident handling and movement tasks will be carried out in accordance with comprehensive nursing and therapy assessments, the Minimum Data Set (MDS) (a federally mandated assessment tool completed by facility staff) and individualized comprehensive care plan, and written instructions pertaining to each individual resident; [...]

Inspectors wroteBased on observation, record review and interview the facility failed to provide a safe and comfortable home like environment when the facility's heating system was not able to maintain comfortable temperatures for the residents. The facility census was 82. Review of the facility's undated Environmental Control Failure policy., showed: -In the event of a system failure resulting in either warmer or cooler than desired temperatures the following process will be adhered to: -Notification of Administrator, Nursing On-Call, IT On-Call and Maintenance On-Call will be completed. -Department managers will attempt corrective action. -In the event temperatures cannot be raised with existing equipment, a contract with Sunbelt Heating and Cooling will be activated. -Sunbelt provides and maintains portable heat pumps. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to prepare, distribute and serve food in accordance with professional standards for food service safety and follow proper sanitation and food handling practices to prevent the possibility of foodborne illness when staff placed their thermometer, used to obtain internal food temperatures prior to serving to the residents, directly into their red bucket filled with sanitizer water after they used the water to wash their food preparation table, placed gloved hands into oven mitts repeatedly without removing their gloves and washing their hands, and kept staff's personal drinks in food preparation areas. The facility's census was 44. Review of the food preparation and handling policy on 3/23/23 shows: [...]

Inspectors wroteBased on record review and interview, the facility failed to implement their water management policy and procedures to reduce the risk of growth and spread of Legionella (bacteria that causes Legionnaires' disease, a serious type of pneumonia). The facility also failed to ensure facility staff were informed on the facility's Water Management Plan and on safe water temperatures to maintain for the hot water. The facility census was 44. Review of the CMS Quality Safety and Oversight (QSO), dated 6/2/17 and revised on 7/6/18, showed: - Facilities must have water management plans and documentation that, at a minimum, ensure each facility: Conducts a facility risk assessment to identify where Legionella (a [NAME] of pathogenic Gram-negative bacteria that includes the species L. [...]

Inspectors wroteBased on record review and interviews, the facility failed to ensure they established and maintained a system that ensured a full, complete and separate accounting according to accepted accounting principles and failed to establish a system that precludes any commingling of resident funds with facility funds. This affected 23 residents (Residents #292, #294, #7, #296, #297, #298, #299, #300, #256, #302, #303. #304, #305, #21, #306, #23, # 308, #309, #41, #310, #13, #319, and #313). The facility's census was 44. Review of the facility's undated Resident Funds Policy showed the facility will, upon written authorization of the resident or their legal representative, manage, safeguard and account for personal funds or money in trust for the resident. [...]

Inspectors wroteBased on observation and interview the facility failed to maintain a safe, clean and comfortable homelike environment. This had the potential the affect all residents in the affected areas. The facility had a census of 44. The requested cleaning policy was not provided. A review of the undated Public Bathroom Cleaning Instructions showed: - Clean the sink and the vanity; - Clean all handles and rails; - Empty trash cans; - Replace toilet paper if low; - Sweep and mop the floor. A review of the undated Cleaning Check list showed: -Ground floor restrooms: o Wipe down walls; o Refill paper products; o Sweep and mop the floor. 1. Observation of the bathroom on the 2nd floor by the social services office on 3/22/23, at 1:52 P.M., showed: -The vent on the ceiling caked with dirt and debris; -Three lights above the mirror covered in dust and debris; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure dependent residents who were unable to carry out activities of daily living (ADLs) received the necessary services to maintain good personal hygiene when staff did not provide complete perineal care which affected four out of 12 sampled residents, (Resident #4, #7, #13, and #18) and when the facility failed to keep Resident #1, #7, #9, and #14 shaved. The facility census was 44. Review of the facility's undated policy for perineal care, showed: - Perineal care is very important in maintaining the residents' comfort and should be done after an incontinent episode; - Perform hand hygiene; -Explain procedure to the resident; -provide privacy; For female residents: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring four of 12 sampled residents, ( Resident #4, #7, #13, and #18) during the use of a mechanical lift transfer. The facility census was 44. Review of the facility's undated policy for mechanical lift transfers, showed in part: - At least two nursing staff will assist in the transfer of a resident when utilizing the mechanical lift; - Roll the lift frame into position with legs in the open position. Legs may be closed to navigate corners or small spaces, but should be in the open position to counter balance resident weight when actively in use with resident; - One staff member operates the lift and the the second staff member guides the movement of the resident while in the lift; [...]

Inspectors wroteBased on interviews and record review, the facility failed to provide adequate staffing to meet the needs of residents due to extended call light response times, causing residents to become incontinent, which affected seven of 12 sampled residents, (Resident # 3, #5, #7, #9, #12, #18 and #253) and call light concerns brought up during resident council. The facility census was 44. Review of the facility's undated policy for silversphere call light system, showed in part: - The facility uses many tools to provide a safe, homelike environment. One took in use is a fully electronic call light system called Silversphere by [NAME]. This system runs through a mobile app, providing privacy and comfort through reduced noise pollution for every resident; - It is the responsibility of every nursing staff member to acquaint themselves with this system, and to respond urgently to all alarms; [...]

Inspectors wroteBased on observation and interview, the facility failed to maintain the exhaust system to remove bathroom odors. The facility census was 44. The requested vent cleaning policy was not provided. 1. Observation of the bathroom on the 2nd floor by the social services office on 3/22/23, at 1:52 P.M., showed the vent on the ceiling caked with dirt and debris. 2. Observation of the bathroom in the basement by the resident salon on 03/22/23, at 4:16 P.M., showed the vent on the ceiling caked with dirt and debris. 3. Observation of the bathroom in the basement by the salon on 3/23/23, at 8:11 A.M., showed the vent on the ceiling continued to be caked with dirt and debris. 4. Observation of the bathroom the 2nd floor by the social services office on 3/23/23 at 10:31 A.M., showed the vent on the ceiling continued to be caked with dirt and debris. 5. Observation on 3/22/23 at beginning at 8:30 A.M. [...]