Health inspection·May 21, 2025

F 0609 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few nurse conducted assessment, lacerations noted between the 3rd and 4th finger on left hand, pressure dressing applied to stop bleeding, and EMS called. Resident#66 was sent to the hospital where she received 7 sutures. This incident was unwitnessed. Weekend Staff nurse reported the incident to the Physician, ADON, and the resident's family member. Record review of Resident #66 nurses progress notes dated 05/11/2025 at 3:49 PM revealed staff found Resident #66 in another resident's room bed. Blood was noted on resident's left hand, resident assessed to find where blood was coming from. Staff nurse found deep laceration on left hand between 3rd and 4th fingers. The resident said, she did not know what happen. Staff nurse cleansed laceration, pressure applied to stop bleeding, no other injury noted. EMS called, transported the resident to ER for treatment of laceration. Documented all parties notified. Record review of Emergency Department (ED) hospital records dated 5/11/2025 revealed Resident presented to ED via EMS evaluation of left-hand laceration. The resident was unclear how she sustained laceration. ED comments: left hand in web space between middle and ring finger, the resident had a 2 cm laceration at the base of the middle finger. ED course of action dated 05/11/2025 at 4:10 Consent obtained for emergent situation, simple repair, number of sutures placed was seven. Record review of Resident #66 nurses progress notes dated 05/11/2025 at 7:17 PM revealed, staff nurse called Resident #66 PR, and indicated Resident #66 had returned to the facility after a laceration repair and had seven stitches between her 2nd & 3rd finger on her left hand. During an observation and interview on 05/19/2025 at 10:30 AM, Resident #66 was in secured unit common area in a wheelchair, noted left hand with 7 sutures, no dressing on left hand, the resident said her hand was sore, but it was better now. Resident #66 could not state how she had cut her hand and sustained the laceration. During an interview on 05/21/2025 at 10:30 AM, ADON said, she was notified by LVN D of the incident on 5/11/2025, indicated that Resident #66 was sent to the hospital to be further treated for laceration. ADON said, she reported the incident to DON immediately, and reviewed the Garden Unit camera's video located in the hallways on the secure units on her cell phone from home. She said, she reviewed the video to track the time of entry and that no one entered the room before or after the resident. She said, the only other entry into the room was when a staff aide found resident in room [ROOM NUMBER], alone. Indicated on 5/12/2025 after further investigation, it was concluded the resident had fallen and gotten herself back up by pulling on the bed frame of the bed which caused the laceration to the hand. She said, the Maintenance department was notified and bed frame was padded. The ADON said she had not witnessed any abuse or neglect and if so, would report it to the DON, and the ADM who was the Abuse Coordinator. During an interview on 05/21/2025 at 10:45 AM, DON said, he was notified by the ADON of the incident that occurred on 05/11/2025. He said, he reviewed the Garden Unit camera's video located in the hallways on the secure units, and notified the ADM who was the Abuse Coordinator. DON said, after further investigation and reviewing the video, on the audio he heard a thump and concluded the resident fell and acquired the lacerations by pulling herself up by the bed frame, which explained the blood on the bed, under bed frames. The DON said he felt this incident was not abuse or neglect, and did not need to be reported to the State Agency. But concluded he had reported the incident to the ADM., and left the decision to the ADM to report the incident to the State Agency. During an interview on 05/21/2025 at 10:55 AM, ADM said, the 05/11/2025 incident was reported to (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675142 If continuation sheet Page 2 of 3 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 05/21/2025 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 0609 Level of Harm - Minimal harm or potential for actual harm her by the DON, and said, she had reviewed the Garden Unit camera's video located in the hallways. ADM said, after further investigation and reviewing the video, on the audio she said, she heard a thump and concluded the resident fell and acquired the lacerations by pulling herself up by the bed frame, which explained the blood on the under-bed frames. The ADM said, she felt this incident was not abuse or neglect, and did not meet the State Agency guidelines in reporting this incident. Residents Affected - Few Record review of the facility's Abuse, Neglect, Exploitation and Reporting Requirements policy revised on 09/08/22 indicated, .If a covered individual reasonably suspects that a crime has occurred against a resident or person receiving care in the health Center, the individual must report the suspicion to the Abuse and/or Neglect Coordinating and follow the Federal/State regulations. If the suspected crime involves serious bodily injury, the incident must be reported within 2 hours .or defined by state regulations . Record review of the facility's Prevention and Reporting: Suspected resident/Patient Abuse, neglect, and or Misappropriation of Property dated 12/2018 indicated, means an injury involving extreme physical pain; . requiring medical intervention such as surgery, hospitalization, Section A 1.1.4: the source of the injury was not observed by any person, or the source of the injury could not be explained by the resident. FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675142 If continuation sheet Page 3 of 3