Health inspection·March 8, 2023

F 0732 Post nurse staffing information every day. Level of Harm - Potential for minimal harm Based on observation, interview, and record review the facility failed to post the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care and resident census on a daily basis for 3 of 3 days (03/06/23, 03/07/23, and 03/08/23) reviewed for March 2023 nursing staffing. Residents Affected - Many The facility failed to post the total number of hours worked for licensed nurses and certified nurse aides or the resident census on the staffing sheet for March 6th , 7th , and 8th of 2023. This failure could cause residents, families, and visitors to be unaware of the facility daily staffing requirements. Findings included: During an observation on 03/06/23 at 08:47 a.m., the total number of hours worked by licensed and unlicensed direct care staff and resident census was not posted on the staffing sheet. The staffing sheet was posted in the front lobby and dated 03/06/23. During an observation on 03/07/23 at 08:17 a.m., the total number of hours worked by licensed and unlicensed direct care staff and resident census was not posted on the staffing sheet. The staffing sheet was posted in the front lobby and dated 03/07/23. During an observation on 03/08/23 at 09:17 a.m., the total number of hours worked by licensed and unlicensed direct care staff and resident census was not posted on the staffing sheet. The staffing sheet was posted in the front lobby and dated 03/08/23. During an interview on 03/08/23 at 10:48 a.m., LVN D said she was the staffing coordinator and responsible for posting the staffing sheet daily. LVN D said she did not know the staffing sheets needed to include documentation of the actual staff hours worked each shift, and the resident census. LVN D said she had only worked in this positions for 3 weeks and was using the staffing sheet used by the person she replaced. LVN D said she would correct it. During an interview on 03/08/23 at 11:00 a.m., the DON said LVN D was the staffing coordinator, and she was responsible for posting the staffing sheet daily. The DON said he was unfamiliar with the posting requirements and did not know the staffing sheets needed to include documentation of the actual staff hours worked each shift, and the resident census. The DON said the staffing sheet needed to be corrected and updated with the total hours worked and resident census and would talk to LVN D about it. The DON said the staffing sheet will be updated and corrected today. Page 1 of 3 675142 675142 03/08/2023 Briarcliff Health Center 3403 S Vine Ave Tyler, TX 75701

F 0732 Level of Harm - Potential for minimal harm Residents Affected - Many During an observation on 03/08/23 at 12:35 p.m., the total number of hours worked by licensed and unlicensed direct care staff and resident census was posted on the staffing sheet. The staffing sheet was posted in the front lobby and dated 03/08/23. Record review of the facility policy Daily Work Assignments dated 12/2018 indicated, .7. Maintain/post the daily work assignment sheets as required by State law. 675142 Page 2 of 3 675142 03/08/2023 Briarcliff Health Center 3403 S Vine Ave Tyler, TX 75701

F 0812 Level of Harm - Minimal harm or potential for actual harm Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. Based on observation, interview and record review, the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 2 ice machines. Residents Affected - Some The facility failed to ensure the large ice machine inside the locked units was clean. These failures could place residents who consumed ice from this machine, at risk of being served in unsanitary conditions and for food borne illness. The findings include: During an observation of the common area to the locked units, on 03/06/2023 at 12:37 p.m., the large ice machine in the common area was dirty with black slimy scum on the inner most portion of the ice machine door, connecting to the inside wall of the ice machine. During an interview with the Dietary Manager on 03/06/2022 at 12:46 p.m., she said the maintenance director is responsible for keeping this ice machine clean. She said she is responsible for cleaning the ice machine in the front and the maintenance director is responsible for cleaning this one in the back. During an interview with the Maintenance Supervisor on 03/06/23 at 12:48 p.m. He said he is responsible for cleaning the ice machine in the common area of the locked units. When asked how often he clean the ice machine, he said every Monday. When asked how he clean the ice machine, the Maintenance Director said he wipes the ice machine down, on the sides and the top of the door. He said he does not keep a record when he cleans the ice machine. During an interview with LVN-C, on 03/06/23 at 2:05 p.m., she said they use the ice from the ice machine in the common area for the locked units for the residents. She said they use the ice to fill cooler, for ice cups, for water pitchers to pass meds, coolers for UA's (urine specimens) and for family members that may have a birthday party. The facility provided a policy dated September 2018, titled Nutrition Services Practice Manual 7.23.1 Sanitation. Procedure Ice Machine, #3 Wash interior and exterior thoroughly using a clean cloth soaked in warm detergent solution. 675142 Page 3 of 3