Briarcliff Skilled Nursing: Burn Injuries, Unsafe Drugs - TX
CARTHAGE, TX. Resident #3 suffered second-degree burns on both thighs from scalding coffee, and administrators spent weeks scrambling to implement basic safety measures they should have had in place all along.
The coffee that burned the resident was served without temperature monitoring. Staff had no policy for checking liquid temperatures. Nobody assessed which residents might be at risk from hot beverages.
Twenty-eight residents regularly drink coffee at Briarcliff Skilled Nursing Facility. Fourteen require staff assistance to get their coffee. Coffee was available to all residents at all times throughout the day, with no safety protocols in place.
Federal inspectors found the coffee burn was just the beginning. They documented a cascade of medication errors, infection control failures, and basic safety violations that put dozens of residents at risk.
Resident #30 received oxygen at nearly double the prescribed rate for days. Her physician ordered 2 liters per minute as needed for shortness of breath. Inspectors found her oxygen concentrator set at 3.5 to 4 liters per minute during multiple observations across three days.
"By not having Resident #30's oxygen at the prescribed rate, she was at risk for not receiving enough oxygen or receiving too much oxygen," LVN L told inspectors after discovering the error. The licensed vocational nurse said he was responsible for ensuring oxygen was set at the ordered rate, but the electronic medication system didn't flag oxygen settings as a task to check.
The Director of Nursing expected oxygen to be set at the ordered amount during morning rounds. The Administrator said failure to follow physician orders could cause respiratory failure.
In the medication storage room, the Director of Nursing kept controlled substances awaiting disposal in an unlocked basket. Inspectors found lorazepam, acetaminophen-codeine, clonazepam, and tramadol tablets sitting in the closet with no documentation of when they arrived or how many pills remained.
The DON said she didn't log the narcotic medications until the pharmacist came for destruction, claiming this was how she had been taught. The facility's own policy required a controlled medication disposition log with resident names, medication details, quantities, dates, and witness signatures.
The last medication destruction occurred months earlier. No records tracked the controlled substances between collection and disposal.
Staff left medication carts unlocked and unattended while family members walked nearby. RN K forgot to lock her cart after retrieving supplies, acknowledging that "anyone could access it and residents could take medications that did not belong to them."
LVN M left her medication cart unlocked while checking a resident's blood sugar in another room. She blamed nervousness from being observed by state surveyors, but admitted "anyone could get ahold of something they should not get ahold of."
Resident #30 kept a bottle of Geri Lanta antacid in her nightstand drawer and a medicine cup filled with white powder on top of her nightstand. She had no order to self-medicate and told inspectors she didn't know what the powder was or who brought it.
The infection control violations were equally widespread. CNA A fed two residents simultaneously during lunch service, alternating spoonfuls between Resident #2 and Resident #5 without sanitizing her hands. She touched one resident's chin, wiped mouths with the same napkin, and continued feeding both residents with the same unwashed hands for 14 minutes.
"I could have transferred germs back and forth to both residents," CNA A admitted. "The residents could get sick if I did not sanitize my hands properly."
LVN G performed wound care on Resident #55's sacral wound without changing gloves between removing the dirty dressing and applying the clean one. She cleaned the wound with contaminated gloves, acknowledging she "could introduce germs back into the wound."
The facility used the wrong disinfectant to clean rooms of residents with C. diff infections. Housekeeping staff used DC 33 cleaner throughout the facility, including in isolation rooms, despite the product label showing it doesn't kill C. diff spores.
"The disinfectant was not killing the spores of c-diff and it had the potential to spread to someone else in the facility," the Assistant Director of Nursing said after inspectors pointed out the error.
Housekeeping Supervisor H had been using DC 33 for an extended period. She never checked whether the cleaner killed C. diff bacteria, saying "the facility had always used the DC 33 and the c-diff had not spread."
Staff repeatedly failed to use required protective equipment when caring for residents on enhanced barrier precautions. LVN C administered multiple medications through Resident #5's feeding tube wearing only gloves, no gown. RN K gave IV antibiotics to Resident #14 through her PICC line without any protective equipment. The Treatment Nurse provided tracheostomy care to Resident #74 wearing gloves but no gown.
Each of these residents had physician orders requiring enhanced barrier precautions during high-contact care activities.
In the kitchen, inspectors found approximately six baking sheet pans with thick black carbon buildup on the rims. The stove top was covered in carbon deposits and white, yellow, and brown substances down the left side.
Nutritional Aide T, responsible for cleaning pots and pans, said the carbon buildup "had been on the pots, pans and baking sheets for some time." She cleaned the stove top only once monthly and said the buildup "could cause a fire."
The Dietary Manager contacted maintenance about the stove residue that "would not come off." The Maintenance Supervisor had no records of recent stove service and couldn't locate documentation of equipment inspections despite a work order system that claimed monthly kitchen inspections.
Residents complained repeatedly about food quality. Four residents told inspectors the meals were terrible, bland, cold, and unappetizing. Resident #57 said "whoever made the menu did not consider they are Senior citizens with dentures, few teeth or no teeth and the flavor was not good."
When inspectors and the Dietary Manager sampled a lunch tray together, the state surveyors found the meal "did not present appetizing with bland mixed veggies, pureed pork chop was too salty and lacked palatability and was received lukewarm."
The Administrator acknowledged food complaints could cause "a decrease in the quality of life and weight loss if a resident consistently did not like the food that was served." The facility completed test trays monthly instead of weekly as required by their own procedures.
Social Worker F said residents complained the food was cold and they didn't like their choices. She reported complaints to administration, but no grievances appeared on the facility's grievance log regarding food issues.
After the coffee burn triggered immediate jeopardy findings, administrators scrambled to implement emergency corrections. They ordered proper disinfectant, conducted hasty staff training sessions, and began checking coffee temperatures.
The facility's plan included hot liquid risk assessments for all residents, coffee temperature logs, and enhanced monitoring by the Quality Assurance Committee. Staff received in-service training on when residents should receive coffee in cups with lids.
But the pattern was established. Basic safety measures implemented only after a resident was burned. Infection control protocols followed only after inspectors intervened. Equipment cleaned only after violations were documented.
The Administrator said he expected physician orders to be followed and proper hand sanitizer procedures to be performed. The expectation came after months of violations that put residents at risk for burns, medication errors, infections, and respiratory complications.
Full Inspection Report
The details above represent a summary of key findings. View the complete inspection report for Briarcliff Skilled Nursing Facility from 2025-01-30 including all violations, facility responses, and corrective action plans.
Additional Resources
Data source: Official federal inspection data from the Centers for Medicare & Medicaid Services (CMS).
Editorial process: AI-synthesized regulatory data, reviewed for accuracy by our editorial team.
Professional review: All content reviewed by Christopher F. Nesbitt, Sr., NH EMT & BU-trained Paralegal.
Last verified: June 20, 2026 · Our methodology
BRIARCLIFF SKILLED NURSING FACILITY in CARTHAGE, TX was cited for violations during a health inspection on January 30, 2025.
The coffee that burned the resident was served without temperature monitoring.
Health inspections identify deficiencies that facilities must correct. Violations range from minor documentation issues to serious safety concerns. Review the full report below for specific details and facility response.