Health inspection·May 30, 2024

F 0849 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Arrange for the provision of hospice services or assist the resident in transferring to a facility that will arrange for the provision of hospice services. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 4 residents (Residents #1, Resident #2, and Resident #3) reviewed for hospice services. The facility did not ensure Resident #1, #2 and #3's hospice skilled nurse progress notes were a part of the resident records in the facility. This failure could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs. Findings included: 1. Record review of the face sheet dated 5/30/24 indicated Resident #1 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, pain, dementia, and anxiety disorder. Record review of the care plan last revised on 3/31/24 indicated Resident #1 was receiving hospice services. Record review of the Hospice Interdisciplinary Group (IDG) Comprehensive Assessment Plan of Care Report dated 5/7/24 indicated Resident #1's most recent IDG meeting was on 4/26/24, The Hospice IDG Comprehensive Assessment Plan of Care Report indicated Resident #1 would have a skilled nurse visit once a week for 8 weeks. Record review of Resident #1's hospice binder on 5/30/24 indicated there was only one skilled nurse note for Resident #1 dated 4/29/24. Record review of the facility's contract with Resident #1's hospice provider dated 11/11/21 indicated, .Hospice staff visit will be scheduled based on the need of the hospice patient according to the agreed upon plan of care .Information/Documentation provided to facility on admission of hospice patient for non-inpatient hospice services and ongoing .f. copies of clinical notes after each visit . 2. Record review of the face sheet dated 5/30/24 indicated Resident #2 was an [AGE] year-old female (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 3 Event ID: 675142 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 05/30/2024 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)