Health inspection·August 13, 2024

F 0677 Provide care and assistance to perform activities of daily living for any resident who is unable. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 4 of 6 (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for ADLs. Residents Affected - Some The facility did not provide scheduled showers for Resident #1, Resident #2, Resident #3, and Resident #4 These failures could place residents at risk of not receiving services/care and decreased quality of life. Findings included: 1. Record review of the face sheet dated 8/13/24 indicated Resident #1 was an [AGE] year-old female, admitted to the facility on [DATE] with diagnoses including Alzheimer's disease (a progressive disease that destroys memory and other important mental functions), dementia, anxiety, and depressive disorder. Record review of the MDS dated [DATE] indicated Resident #1 was understood by others and usually understood others. The MDS indicated Resident #1 had a BIMS of 03 indicating she was severely cognitively impaired. The MDS indicated Resident #1 did not reject care. The MDS indicated Resident #1 required supervision or touching assistance with showers/bathing. Record review of the care plan last revised 6/11/24 indicated Resident #1 required full time nursing care and will be admitted for long term placement. Record review of an undated shower schedule indicated Resident #1 was scheduled for showers on Mondays, Wednesdays, and Fridays on the 6:00 a.m. to 2:00 p.m. shift. Record review of the July 2024 calendar indicated Mondays, Wednesdays, and Fridays for this month were on the following dates: 7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/10/24, 7/12/24, 7/15/24, 7/17/24, 7/19/24, 7/22/24, 7/24/24, 7/26/24, 7/29/24, and 7/31/24. Record review of the facility's shower sheets for July 2024 indicated there were not any shower sheets for Resident #1. Record review of the August 2024 calendar through August 13, 2024, indicated the Mondays, Wednesdays, and Fridays for this month were on the following dates: 8/2/24, 8/5/24, 8/7/24, 8/9/24, and Page 1 of 5 675142 675142 08/13/2024 Briarcliff Health Center 3403 S Vine Ave Tyler, TX 75701

F 0677 8/12/24. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's shower sheets for August 2024 indicated Resident #1 received a shower on 8/12/24. Residents Affected - Some Record review of the ADL Category Report dated 7/7/24 through 8/12/24 indicated Resident #1 had not received any showers/bathing. 2. Record review of face sheet dated 8/13/24 indicated Resident #2 was a [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, psychotic disorder with delusions (a disorder having false or fixed belief involving a real-life situation that could be true but is not), and muscle wasting and atrophy (the gradual loss of muscle tissue, size, and strength). Record review of the MDS dated [DATE] indicated Resident #2 was rarely/never understood by others and rarely/never understood others. The MDS indicated Resident #2 did not have a BIMS score. The MDS indicated Resident #2 rejected care 4-6 days out of 7 but not daily. The MDS indicated Resident #2 required substantial/maximum assist with showers/bathing. Record review of the comprehensive care plan last revised 8/6/24 indicated Resident #2 had an ADL self-care deficit and required assistance with A) Oral care B) Dressing C) Transfers D) Bathing E) Grooming F) Eating related to weakness, decreased mobility, and altered mentation with interventions including assist with bathing, dressing, and grooming daily and as needed. Record review of an undated shower scheduled indicated Resident #2 was scheduled for showers on Mondays, Wednesdays, and Fridays on the 2:00 p.m. to 10:00 p.m. shift. Record review of the July 2024 calendar indicated the Mondays, Wednesdays, and Fridays for this month were on the following dates: 7/1/24, 7/3/24, 7/5/24, 7/8/24, 7/10/24, 7/12/24, 7/15/24, 7/17/24, 7/19/24, 7/22/24, 7/24/24, 7/26/24, 7/29/24, and 7/31/24. Record review of the facility's shower sheets for July 2024 indicated Resident #2 received a shower on 7/23/24. Record review of the August 2024 calendar through August 13, 2024, indicated the Mondays, Wednesdays, and Fridays for this month were on the following dates: 8/2/24, 8/5/24, 8/7/24, 8/9/24, and 8/12/24. Record review of the facility's shower sheets for August 2024 indicated Resident #2 received showers on 8/7/24 and 8/12/24. Record review of the ADL Category Report dated 7/7/24 through 8/12/24 indicated Resident #2 received a shower/bath on 7/26/24 7/29/24, 7/31/24, 8/1/24, and 8/12/24. 3. Record review of the face sheet dated 8/13/24 indicated Resident #3 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, depression, and restless leg syndrome (a condition characterized by a nearly irresistible urge to move the legs, typically in the evenings). 675142 Page 2 of 5 675142 08/13/2024 Briarcliff Health Center 3403 S Vine Ave Tyler, TX 75701

F 0677 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of the MDS dated [DATE] indicated Resident #3 usually understood others. The MDS indicated Resident #3 had a BIMS of 06 indicating she was severely cognitively impaired. The MDS indicated Resident #3 rejected care 1-3 days out of 7. The MDS did not indicate Resident #3's functional status with showers/bathing. Record review of the comprehensive care plan last revised 5/30/24 indicated Resident #3 had an ADL self-care deficit. Resident required assist with transfers, oral care, dressing, eating, grooming, and bathing related to decreased mobility, weakness, and altered mentation with interventions including assist resident with bathing as needed. Record review of an undated shower schedule indicated Resident #3 was scheduled for showers on Tuesdays, Thursdays, and Saturdays on the 2:00 p.m. to 10:00 p.m. shift. Record review of the July 2024 calendar indicated Tuesdays, Thursdays, and Saturdays were on the following dates: 7/2/24, 7/4/24, 7/6/24, 7/9/24, 7/11/24, 7/13/24, 7/16/24, 7/18/24, 7/20/24, 7/23/24, 7/25/24, 7/27/24, and 7/30/24. Record review of the facility's shower sheets for July 2024 indicated Resident #3 received a shower/bath on 7/4/24 and 7/8/24. Record review of the August 2024 calendar through August 13, 2024, indicated Tuesdays, Thursdays, and Saturdays were on the following dates: 8/1/24, 8/3/24, 8/6/24, 8/8/24, 8/10/24, and 8/13/24. Record review of the facility's shower sheets for August 2024 indicated Resident #3 received showers on 8/10/24 and 8/12/24. Record review of the ADL Category Report dated 7/7/24 through 8/12/24 indicated Resident #3 did not receive a shower/bath. 4. Record review of the face sheet dated 8/13/24 indicated Resident #4 was a [AGE] year-old male, re-admitted to the facility on [DATE] with diagnoses including Alzheimer's disease, dementia, depression, and anxiety. Record review of the MDS dated [DATE] indicated Resident #4 was usually understood by others and usually understood others. The MDS indicated Resident #4 had a BIMS of 01 indicating he was severely cognitively impaired. The MDS indicated Resident #4 rejected care 1-3 days out of 7. The MDS indicated Resident #4 required substantial/maximum assist with showers/bathing. Record review of the comprehensive care plan last revised 8/9/24 indicated Resident #4 had an ADL self-care deficit. Resident requires assist with transfers, oral care, dressing, eating, grooming, and bathing related to decreased mobility, weakness, and altered mentation with interventions including assist resident with bathing as needed. Record review of an undated shower scheduled indicated Resident #4 was scheduled for showers on Tuesdays, Thursdays, and Saturdays on the 2:00 p.m. to 10:00 p.m. shift. Record review of the July 2024 calendar indicated Tuesdays, Thursdays, and Saturdays were on the following dates: 7/2/24, 7/4/24, 7/6/24, 7/9/24, 7/11/24, 7/13/24, 7/16/24, 7/18/24, 7/20/24, 7/23/24, 7/25/24, 7/27/24, and 7/30/24. 675142 Page 3 of 5 675142 08/13/2024 Briarcliff Health Center 3403 S Vine Ave Tyler, TX 75701

F 0677 Level of Harm - Minimal harm or potential for actual harm Record review of the facility's shower sheets for July 2024 indicated there was not any shower sheets for Resident #4. Record review of the August 2024 calendar through August 13, 2024, indicated Tuesdays, Thursdays, and Saturdays were on the following dates: 8/1/24, 8/3/24, 8/6/24, 8/8/24, 8/10/24, and 8/13/24. Residents Affected - Some Record review of the facility's shower sheets for August 2024 indicated Resident #4 received showers on 8/3/24 and 8/11/24. Record review of the ADL Category Report dated 7/7/24 through 8/12/24 indicated Resident #4 received a shower on 8/12/24. During an interview on 8/13/24 at 1:17 p.m. CNA B said residents received their showers on a schedule and was either scheduled on the 6:00 a.m.-2:00 p.m. shift or the 2:00 p.m.-10:00 p.m. shift and Monday, Wednesday, and Friday or Tuesday, Thursday, and Saturday. CNA B said if a resident refused their shower they should be reapproached again later, and the charge nurse should be notified. CNA B said showers were not documented in the computer system, they were documented on shower sheets. CNA B said all shower sheets were turned into the nurses. CNA B said the importance of residents receiving their scheduled showers was to prevent skin breakdown and hygiene. During an interview on 8/13/24 at 1:20 p.m. CNA C said she usually worked the 6:00 a.m.-2:00 p.m. shift in the women's secured unit. CNA C said residents received their showers 3 times a week as scheduled and as needed. CNA C said Resident #3 sometimes refused showers if she was worked up. CNA C said Resident #1 did not refuse showers often and was easily re-directed. If Resident #1 was too worked up, she would refuse a shower and would get a bed bath instead. CNA C said if a resident refused a shower the charge nurse should be notified, and the resident should be reapproached later. CNA C said the importance of the residents receiving their scheduled showers was hygiene. During an interview on 8/13/24 at 1:25 p.m. LVN A said she was a charge nurse in the memory care unit. LVN A said residents received their showers 3 times a week on schedule. LVN A said Resident #1 rarely refused showers and was easily re-directed if she refused. LVN A said Resident #3 rarely refused showers. LVN A said if a resident refused their shower staff should try again at a later time. LVN A said the importance of residents receiving their scheduled showers was their hygiene and health. LVN A said showers were documented on shower sheets and in the computer. LVN A said if showers were not documented it could not be proved they were completed. During an interview on 8/13/24 at 2:00 p.m. the DON said he expected showers to be given as scheduled and as needed. The DON said the facility did have some difficult residents who sometimes required family intervention to get them to shower. The DON said if a resident was being combative towards staff, he did not for both the resident and staff's safety expect staff to pursue a shower at that time. The DON said if a resident was combative or refused a shower, he expected staff to reapproach the resident later or get another staff member to reapproach the resident. The DON said showers were documented on shower sheets and turned in to the unit managers. The DON said he retrieved the shower sheets daily prior to morning meeting. The DON said if a shower was not documented that it had been completed it could not be proven the resident received their shower. The DON said the importance of resident receiving their scheduled showers was infection control, skin integrity, and quality of life. During an interview on 8/13/24 at 2:29 p.m. the Regional Nurse Consultant said the facility did not 675142 Page 4 of 5 675142 08/13/2024 Briarcliff Health Center 3403 S Vine Ave Tyler, TX 75701

F 0677 have a policy regarding ADLs specifically. Level of Harm - Minimal harm or potential for actual harm Record review of the facility's Bathing-Shower Procedure dated March 2019 indicated, [The] purpose [was] to provide personal hygiene [and] to stimulate circulation .Record bath as applicable. Residents Affected - Some Record review of the facility's Bathing-Tub Procedure dated March 2019 indicated, [The] purpose [was] to provide personal hygiene, to stimulate circulation, [and] to reduce tension for the resident/patient .document bath on the bath record. Record review of the facility's Bed Bath-Complete Procedure dated March 2019 indicated, [The] purpose [was] to provide personal hygiene, to stimulate circulation, [and] to promote muscular relaxation and relieve fatigue .Report to Nurse any pertinent observations of resident/patient during bathing including condition of skin. Record review of the facility's Bed Bath-Partial Procedure dated March 2019 indicated, [The] purpose [was] to provide personal hygiene, to stimulate circulation, [and] to promote muscular relaxation and relieve fatigue .Report to Nurse any pertinent observations of resident/patient during bathing including condition of skin. 675142 Page 5 of 5