Health inspection·April 10, 2024

F 0644 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few who admitted to the facility on [DATE] with diagnoses which included psychotic disorder with delusions (a disorder in which the affected person has a distorted sense of reality and cannot distinguish the real from the unreal) and bipolar disorder (a disorder associated with episodes of mood swings ranging from depressive lows to manic highs). Record review of Section I of the Comprehensive (admission) MDS assessment, dated 06/22/2023, indicated Resident #92 had a diagnosis of bipolar disorder. Section N of the same MDS assessment indicated Resident #92 had received antipsychotic medication for 7 of 7 days of the assessment period. Record review of a physician's order dated 06/15/2023 indicated Resident #92 was receiving the medication, Remeron, for treatment of bipolar disorder. Record review of Resident #92's PASRR Level 1 Screening completed on 06/14/2023 indicated in section C0100 there was no evidence of this individual having mental illness. During an interview on 04/10/2024 with MDS Nurse B, she said the MDS department was responsible for PASRR functions. She said the Skilled MDS Nurse was assigned the task of reviewing the Level 1 PASRRs to ensure accuracy and appropriate follow-up actions. She said the person who would have reviewed Resident #17's PASRR Level 1 was no longer working at the facility. MDS Nurse B said the LA should have been notified of Resident #17's and Resident #92's inaccurate PASRR Level 1 screenings. She said a Form 1012 should have been completed for Resident #17 since Resident #17 had a primary diagnosis of dementia. MDS Nurse B said it was important for the PASRR Level 1 Screening to be accurate because the facility needed to make sure the residents were getting the correct resources. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675142 If continuation sheet Page 2 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briarcliff Health Center 3403 S Vine Ave Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 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 beverage service areas. (ABC halls common dining area). The facility failed to ensure the large ice machine outside of the main kitchen, the ice dispenser, and the coffee and iced tea dispensers in the ABC halls common dining area were clean. These failures could place residents who consumed ice, coffee and tea from these machines, at risk of being served in unsanitary conditions and for food borne illness. Findings included: During an observation of the ABC halls common dining area, on 04/08/2024 at 12:37 PM, revealed the ice machine in the common dining area was dirty with black, slimy scum, and rust build up on the entire grate of the drain of the ice dispenser machine. During an observation of the ABC halls common dining area, on 04/09/2024 at 5:30 PM, revealed the ice machine in the common dining was dirty with black, slimy scum, and rust build up on the entire grate of the drain of the ice dispenser machine. During an observation of the ABC halls common dining area, on 04/10/2024 at 9:00 AM, the ice machine in the common dining was dirty with black, slimy scum, and rust build up on the entire grate of the drain of the ice dispenser machine, the coffee and tea dispensers were dirty with slimy build up and the filter basket had rusted, and the rusted water ran into the tea. During an interview with the DM on 04/10/2024 at 09:00 AM, she said dietary was responsible for keeping the ice, coffee, and tea dispenser machines clean. She said she was responsible for cleaning the ice machine outside of the kitchen. She said, I guess we didn't clean the coffee and tea dispensers. During an interview with the Morning [NAME] A on 04/10/2024 at 09:15 AM., he said dietary was responsible for keeping the ice, coffee, and tea dispenser machines clean. He said he usually would come out after each meal and clean the three dispensers, but he had been off and could not account for what someone else does. Record Review of the Dietary Cleaning Log, there was not a cleaning schedule for the tea dispenser. During an interview with the DM on 04/10/2024 at 11:10 AM, she, the new company has changed the cleaning schedule form and the beverage bar was left off, but she said she would make sure it gets added on. Record review of an undated policy, Sanitation . #12 Ice Machine and ice storage containers will be drained, cleaned and sanitized per manufacturer's instructions. The dietary department will clean ice machines weekly or/and as needed. #14 Coffee area cleaned daily. Review of the FDA Food Code 2022: 4-6 Cleaning of Equipment, (A) EQUIPMENT FOOD-CONTACT SURFACES and UTENSILS shall be clean to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675142 If continuation sheet Page 3 of 4 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 675142 B. Wing A. Building (X3) DATE SURVEY COMPLETED 04/10/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briarcliff Health Center 3403 S Vine Ave Tyler, TX 75701 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)

F 0812 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some sight and touch. Pf (B) The FOOD-CONTACT SURFACES of cooking EQUIPMENT and pans shall be kept free of encrusted grease deposits and other soil accumulations. (C) Nonfood-CONTACT SURFACES of EQUIPMENT shall be kept free of an accumulation of dust, dirt, FOOD residue, and other debris. (E) Except when dry cleaning methods are used as specified under § 4-603.11, surfaces of UTENSILS and EQUIPMENT contacting FOOD that is not TIME/TEMPERATURE CONTROL FOR SAFETY FOOD shall be cleaned: (4) In EQUIPMENT such as ice bins and BEVERAGE dispensing nozzles and enclosed components of EQUIPMENT such as ice makers, cooking oil storage tanks and distribution lines, BEVERAGE and syrup dispensing lines or tubes, coffee bean grinders, and water vending EQUIPMENT: (a) At a frequency specified by the manufacturer, or(b) Absent manufacturer specifications, at a frequency necessary to preclude accumulation of soil or mold. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675142 If continuation sheet Page 4 of 4