Briarcliff Skilled Nursing Facility
BRIARCLIFF SKILLED NURSING FACILITY in CARTHAGE, TX — inspection on January 30, 2025.
Found 10 citations. Severity: Standard violations.
Health inspections identify deficiencies that facilities must correct within required timeframes. Violations range from minor documentation issues to serious safety concerns and are subject to follow-up verification.
Inspection Findings
Coordinator indicated without the support of the safety belt and harness, she would be confined to her
she is able to interact with her community to the best of her ability.
The risk of falls and need for the
seamlessly with the resident's care plan, supporting her participation in essential routines and complement other safety measures within the care plan.
The PASRR Habilitation Coordinator said in her opinion that this comprehensive approach to safety allows for a more holistic care strategy, encouraging Resident #5's engagement in meaningful activities while minimizing risks. It becomes part of a larger framework designed to balance safety concerns with the pursuit of a fulfilling and active lifestyle.
Record review of the Resident Rights Policy last revised August 14, 2022, revealed .staff will abide by resident rights as outlined within CMS State Operations Manual Appendix PP- Guidance to Surveyors for Long Term Care Facilities (Rev. 11-22-17).
676051 01/30/2025
Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633
2024, revealed . the RAI process was the basis for the accurate assessment of each resident . trunk
limited to . vest . belts used in a wheelchair that either restricts freedom of movement or access to
equipment that the resident cannot easily remove, that restricts movement of any part of . lower extremity . that either restricts freedom of movement or access to their own body .
Record review of the facility's policy titled Resident Assessment with a revised date of January 12, 2020 indicated . purpose . to assess each resident's strengths, weaknesses, and care needs . to use the assessment date to develop a person-centered comprehensive plan of care for each resident that would assist a resident in achieving and maintaining the highest practical level of mental functioning, physical functioning, and wellbeing as possible . it is the Standard of Care at the facility to conduct, initially and periodically, a comprehensive, accurate assessment of each resident's functional capacity utilizing the MDS according to the guidelines set forth in the RAI manual .
Completing the Care Area Assessments (CAAs) .
Upon completion of comprehensive assessments (as defined by the RAI Manual), CAAs will be triggered to flag areas of concern that may need to be addressed in the POC for that resident.
Each triggered CAA will be reviewed by designated staff to determine if a triggered condition affects the resident's function and quality of life or if the resident is at significant risk of developing the triggered condition.
Additional assessments will be conducted, if needed to obtain and document additional information on a care area. CAA documentation will be done following guidelines in the RAI Manual and will state whether or not a care plan is needed to address the triggered area and the rationale for arriving at this decision.
While CAAs identify common areas of concern in nursing home residents, the POC is not to be limited to the triggered areas.
The comprehensive POC must address all care issues that are relevant to the individual, whether or not they are specifically covered in the MDS/CAA process .
676051 01/30/2025
Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633
assessment completed on admission, re-admission, quarterly, and if the resident had a change in
jeopardy to resident health or stroke, new tremors, etc .
Any resident with increased risk for injury was to be reviewed by the IDT safety (Interdisciplinary Team) for appropriate interventions.
Care plan to be updated and staff to implement interventions deemed appropriate.
The in-service included signatures of ADON, RN K, LVN M, DON,
attached to the in-service. *
Record review of a T[TRUNCATED]
676051 01/30/2025
Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633
During an observation and interview on 01/29/25 at 2:31 PM, LVN L, said he was Resident #30's nurse. LVN L entered Resident #30's room and observed the settings on the concentrator and he said Resident #30 oxygen was set at 4 l/min. LVN L reviewed Resident #30's physician orders and said Resident #30's oxygen should have been set at 2 l/min. LVN L said since Resident #30 oxygen was only for as needed, it did not show on the electronic MAR as a task to check her oxygen settings. LVN L said 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 said the nurse was responsible for ensuring the oxygen was set at the ordered rate.
During an interview on 01/30/25 at 8:49 AM, the DON said she expected oxygen to be set at the ordered amount.
The DON said the nurse was responsible for following physician orders and for ensuring the oxygen was set at the ordered rate during their morning rounds.
During an interview on 01/30/25 at 9:33 AM, the Administrator said he expected physician's orders to be followed.
The Administrator said failure to set the oxygen at the ordered rate could cause respiratory failure if too little oxygen was received and unsure of what could happen if the resident received too much oxygen.
The Administrator said nursing staff was responsible for ensuring the oxygen was set at the ordered rate.
Record review of the facility's policy and procedure Applying an oxygen delivery device revised January 12, 2020, indicated .
Staff will apply oxygen delivery devices in accordance with standard practice guidelines.
Procedure: Identify the resident.
Validate physician orders .
Attach oxygen delivery device as required .
Verify setting on flowmeter and oxygen source and the prescribed flow rate .
Record the procedure in the record .
Medications dated [DATE], indicated .
Policy . 2.
Medications included in the Drug Enforcement
in accordance with federal and state laws and regulations .
Procedure . 2.
Controlled Substances
discontinued are retained in the nursing care center in a securely double locked are with restricted access until destroyed as outlined by state regulation . c. A controlled medication disposition log, or equivalent form, shall be used for documentation and shall be retained as per federal privacy and state regulations.
This log shall contain the following information: Resident's name, medication name and strength, prescription number, quantity/amount disposed, date of disposition, signatures of the required witnesses .
676051 01/30/2025
Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633
During an interview on 01/30/25 at 08:36 AM, the ADON said she expected medication carts to be locked when left unattended and medications not to be left at the bedside.
The ADON said by leaving the medication cart unlocked anyone could get into the cart and could cause a danger to a resident if they took something they were not supposed to.
The ADON said by leaving medications at the bedside, staff would be unaware of who had taken the medication and would not be able to accurately monitor the resident.
The ADON said it was the nurses and medication aides' responsibility to ensure carts were locked when left unattended and no medications were left at bedsides.
During an interview on 01/30/25 at 8:49 AM, the DON said medications carts should not be left unlocked when left unattended.
The DON said by leaving the medication cart unlocked anyone could get into them.
The DON said medications should not be left at the bedside because residents should not be administering medications by themselves.
The DON said the nurses and medication aides were responsible for ensuring medication carts were locked when left unattended and mediations were not left at the residents' bedside.
During an interview on 01/30/25 at 09:33 AM, the Administrator said medication carts were not to be left unlocked when leaving them unattended. He said there was a potential for medications to go missing, residents or staff members getting to them, or resident harm if they consumed a medication that was not theirs.
The Administrator said medications should not be left at the bedside because the facility needed to ensure the residents received the right medication and right medication dose.
The Administrator said the nurse or medication aide was responsible for ensuring the carts were locked when left unattended but any staff member, when passing by, could lock them if they noticed they were unlocked.
The Administrator said all staff were trained to take note medications were not at bedsides and to remove them if found.
Record review of the facility's policy Medication Storage, dated January 2024, indicated .Medications and biologicals are stored properly, following manufacturers or provider pharmacy recommendations, to keep their integrity and to support safe, effective drug administration.
The medication supply shall be accessible only to licensed nursing personnel, pharmacy personnel, or staff members lawfully authorized to administer medications. 1.
The provider pharmacy dispenses medications in containers that meet state and federal labeling requirements, including those established by the United States Pharmacopeia (USP).
Medications are to remain in these containers and stored in a controlled environment.
This may include such containers as medication carts, medications rooms, medication cabinets, or other suitable containers .3. In order to limit access to prescription medications, only licensed nurses, pharmacy staff, and those lawfully authorized to administer medications (such as medication aides) are allowed access to medication carts.
Medication rooms, cabinets and medication supplies should remain locked when not in use or attended to by persons with authorized access Record review of the facility's policy and procedure Medication Administration- General Guidelines, dated January 2024, indicated .17.
During administration of medications, the medication cart is kept closed and locked when out of sight of the medication nurse
676051 01/30/2025
Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633
During delivery .a.
Select random samples of regular and pureed meals . b. assesses accuracy, presentation, garnish, and portions served .3. At the end of meal service: a.
Obtain and sample of each food from the regular and pureed b.
Hold the sample for an appropriate amount of time .c.
Identify compliance to the 7 review points .4. In the space provided at the end of the form, add details of any corrective actions taken and other comments as needed.
676051 01/30/2025
Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633
During an interview on 1/30/2025 at 10:37 AM, the ADM said he did not know the standard on the black carbon buildup on pans, pots, and stove. He said he did not know if the pots, pans, or stove would need to be out of service.
The ADM said he did not know what the black carbon buildup could do if it continued to build up on the surface of pots, pans, or the stove. He said he expected the kitchen to be cleaned according to the facility policy and proper maintenance of equipment.
During an interview on 1/30/2025 at 10:53 AM, the Corporate Regional Dietician said some of the pans could be replaced and the carbon build up was on the underside of the pans.
The Corporate Regional Dietician said she could not say what could happen with black carbon build up on the surfaces of the pans or stove.
She said she expected the black carbon buildup to be cleaned or discarded.
She said the facility would need to add additional areas to clean the sides of the stove more frequently.
The Corporate Regional Dietician said she expected the ranges to be cleaned per the facility policy.
During an interview on 1/30/2025 at 11:38 AM, the Corporate Regional Dietician said the facility did not have a specific policy over equipment cleaning or cleaning schedule.
Record review of facility Cooks Daily/Weekly Duties checklist dated January 2025 revealed Ovens (inside outside, top and bottom) should be cleaned daily with No Exception handwritten on the checklist.
The [NAME] initialed daily the task was completed .
Record review of U.S.
Food and Drug Administration Code Dated 2022 Section 4-6, 4-602.12 Cooking and Baking Equipment. (A)The food-contact surfaces of cooking and baking equipment shall be cleaned at least every 24 hours.
This section does not apply to hot oil cooking and filtering equipment if it is cleaned as specified in Subparagraph 4-602.11(D)(6). (B)The cavities and door seals of microwave ovens shall be cleaned at least every 24 hours by using the manufacturer's recommended cleaning procedure. 4-101.18 Nonstick Coatings, Use Limitation.
Multiuse kitchenware such as frying pans, griddles, saucepans, cookie sheets, and waffle bakers that have a perfluorocarbon resin coating shall be used with nonscoring or nonscratching utensils and cleaning aids.
676051 01/30/2025
Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633
During an interview on 01/30/25 at 8:49 AM, the DON said EBP should been worn when providing care
676051 01/30/2025
Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633
The surveyor verification of the Plan of Removal from 1/29/25 was as follows:
*
Record review of a Training In-Service Form indicated an in-service was held on 1/28/25.
The in-service was presented by the Dietary Manager.
The in-service stated all coffee is transferred to air pot after brewing and dietary staff is to check temp of air pots prior to setting them out for service to ensure temp is below 170 degrees.
The in-service included signatures of DA X, DA W, and the Dietary Manager.
The policy titled Taking Food Temperatures, dated revised August 1, 2024, was attached to the in-service.
*
Record review of a Training In-Service Form indicated an in-service was held on 1/28/25.
The in-service was presented by the DON.
The in-service stated residents were to have a hot liquid risk assessment completed on admission, re-admission, quarterly, and if the resident had a change in condition (COC) that would impact their abilities to handle hot liquids safely, ex.
Broken arm or new stroke, new tremors, etc .
Any resident with increased risk for injury was to be reviewed by the IDT (Interdisciplinary Team) for appropriate interventions.
Care plan to be updated and staff to implement interventions deemed appropriate.
The in-service included signatures of ADON, RN K, LVN M, DON, ADM, LVN L, and LVN R.
The policy titled Hot Liquid Risk Evaluation dated reviewed 1/28/25 was attached to the in-service.
676051
Form Approved OMB
STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: COMPLETED A.
Building 676051 B.
Wing 01/30/2025
NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE
Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633
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Source: This inspection report was downloaded directly from the Centers for Medicare & Medicaid Services (CMS) via Medicare.gov. CMS releases nursing home inspection reports in bulk. The findings reflect what state surveyors documented in the official Form CMS-2567 Statement of Deficiencies on the date of the inspection.
Plan of correction not included: The CMS report we receive does not include the facility's plan of correction. Facilities submit plans of correction separately to their state survey agency and those responses may not appear in CMS public data at the time of release. The absence of a plan of correction in this report does not mean one was not filed. Readers who want information about corrective steps taken by the facility are encouraged to contact the facility or their state survey agency directly.
Corrections may have been made: This report reflects conditions observed on the date of the survey. The facility may have implemented staffing changes, additional training, policy revisions, or other corrective actions since this report was issued. We publish what CMS provides and encourage readers to seek current information from the facility.