Health inspection·October 15, 2024

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for 3 of 10 residents (Resident #2, Resident #3, Resident #10) reviewed for care plans. The facility failed to ensure Resident #2, Resident #3, and Resident #10's care plans reflected the risk of elopement/wandering and their placement in the secure unit. This failure could place residents at risk of not receiving the care and services as indicated in the comprehensive care plans. The findings included: 1. Record review of Resident #2's file dated 10/09/24 reflected an [AGE] year-old female with an original admission date of 06/04/24. Her diagnosis included: unspecified dementia, type 2 diabetes, hypertension, mood disorder, delusional disorders, depression, insomnia, need for assistance with personal care, abnormalities of gait and mobility, cognitive communication deficit, and adult failure to thrive. Record review of Resident #2's MDS assessment dated [DATE] reflected Resident #2 had a BIMS score of 3 (severe cognitive impairment ). Resident #2 had exhibited wandering behaviors which occurred 4 to 6 days, but less than daily. Record review of Resident #2's secure unit placement dated 10/14/24 reflected Resident #2 met criteria for placement on the secure unit as the resident had a diagnosis of dementia or related disorder, history of elopement or exit seeking behaviors, wandered in the hallway, Sundown Syndrome that was not easily redirected by staff, could not identify or avoid unsafe conditions, had memory loss, disorientation, or confusion, required frequent redirection, and wandered into other resident rooms, unable to find their way back to her own room. The care planning section was filled out. Record review of Resident #2's order summary dated 10/14/24 reflected to admit Resident #2 to the female secured unit due to exit seeking behaviors related to diagnosis of dementia. Order date: 06/04/24. Record review of Resident #2's care plan dated 10/09/24 reflected Resident #2 was dependent for meeting emotional, intellectual, physical, and social needs related to dementia. Date initiated: Page 1 of 15 675162 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some 06/10/24. Resident #2 had an ADL self-care performance deficit related to dementia. Date initiated: 06/20/24. The care plan did not reflect the risk of elopement/wandering or that Resident #2 was placed in the secure unit. Record review of Resident #2's wandering evaluation dated 09/10/24 reflected Resident #2 was not at risk of wandering. Comments indicated Resident #2 was able to ambulate at times by herself with unsteady gait, required assistance x 1 or wheelchair at times. Care planning section was not filled out. Interventions/care plans have been: Implemented, re-evaluated, updated (no selection made). 2. Record review of Resident #3's file dated 10/09/24 reflected an [AGE] year-old female with an original admission date of 05/24/24. Her diagnosis included: fibromyalgia ( condition that caused widespread pain, fatigue, and other symptoms), hypertension, type 2 diabetes, cognitive communication deficit, abnormalities of gait and mobility, personal history of transient ischemic attack (stroke), need for assistance with personal care, osteoporosis (weak bones), depression, and vascular dementia (brain damage due to impaired blood flow). Record review of Resident #3's MDS assessment dated [DATE] reflected Resident #3 had a BIMS score of 6 (severe cognitive impairment ). Resident #3 had exhibited wandering behaviors which occurred 4 to 6 days, but less than daily. Record review of Resident #3's wandering evaluation dated 09/12/24 reflected Resident #3 was at risk of wandering. The care planning section was not filled out. Interventions/care plans have been: Implemented, re-evaluated, updated (no selection made which was the incorrect of filling out the form). Record review of Resident #3's secure unit placement dated 07/17/24 reflected Resident #3 met criteria for placement on the secure unit as resident had a diagnosis of dementia or related disorder, history of elopement or exit seeking behaviors, verbalized wanting to go home, Sundown Syndrome that was not easily redirected by staff, could not identify, or avoid unsafe conditions, had memory loss, disorientation, or confusion, and required frequent redirection. The care planning section was not filled out. Record review of Resident #3's order summary dated 10/14/24 reflected Resident #3 may admit to female secured unit due to risk of elopement and history of wandering behavior. Order date: 05/24/24. Record review of Resident #3's care plan dated 10/09/24 reflected Resident #3 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to dementia/depression. Date initiated: 05/31/24. Resident #3 had an ADL self-care performance deficit related to dementia. Date initiated: 06/05/24. The care plan did not reflect the risk of elopement/wandering or that Resident #3 was placed in the secure unit. 3. Record review of Resident #10's file dated 10/09/24 reflected an [AGE] year-old female with an original admission date of 03/28/23. Her diagnosis included: Alzheimer's disease, Sjogren's syndrome (dry mouth, dry eyes), vascular dementia (brain damage due to impaired blood flow), major depressive disorder, hypertension, abnormalities of gait and mobility, gout (form of arthritis), and emphysema (lung disease). Record review of Resident #10's MDS assessment dated [DATE] reflected Resident #10 had a BIMS score of 3 (severe cognitive impairment ). Resident #10 had not exhibited wandering behaviors (as her 675162 Page 2 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0656 health had declined). Level of Harm - Minimal harm or potential for actual harm Record review of Resident #10's wandering evaluation dated 10/04/24 reflected Resident #10 was at risk of wandering. The comments indicated Resident #10 resided in a female secured unit. The care planning section was not filled out. Interventions/care plans have been: Implemented, re-evaluated, updated. Implemented was selected. Residents Affected - Some Record review of Resident #10's secure unit placement dated 09/14/24 reflected Resident #10 met criteria for placement on the secure unit as resident had a diagnosis of dementia or related disorder, history of elopement or exit seeking behaviors, verbalized wanting to go home, stated they will walk home, call the bus, get their car, etc., could not identify or avoid unsafe conditions, had memory loss, disorientation, or confusion, and required frequent redirection. Care planning section was not filled out. Record review of Resident #10's order summary dated 10/14/24 reflected Resident #10 may admit to generations unit due to high risk for elopement related to Alzheimer's disease. Order date: 03/28/23. Record review of Resident #10's care plan dated 10/09/24 reflected Resident #10 was dependent on staff for meeting emotional, intellectual, physical, and social needs related to Alzheimer's Disease. Date initiated: 04/09/23. Resident #10 had an ADL self-care performance deficit related to Alzheimer's, dementia, impaired balance. Date initiated: 05/02/23. The care plan did not reflect the risk of elopement/wandering or that Resident #10 was placed in the secure unit. Observations of Resident #2 and Resident #3 on 10/09/24 at 1:30 PM revealed Resident #2 and Resident #3 resided in the secured unit. Resident #10 was not observed as she was discharged to the hospital during the visit. Interview with CNA B on 10/14/24 at 11:20 AM revealed CNA B said the residents in the secured unit were admitted there because the residents did not understand safety issues or exhibited exit seeking behaviors. CNA B said the residents in the secured unit did not understand what they were doing, and all had Alzheimer's or dementia. CNA B said the residents were placed in the unit for those reasons. Interview with RN E on 10/14/24 at 1:20 PM revealed RN E said the residents that were in the secure unit had dementia or Alzheimer's and were at risk of elopement or wandering. RN E said MDS nurses updated the care plans. RN E said if a resident was in the secured unit, that should have been care planned. RN E said being placed in the unit was an intervention for those that were at risk of elopement. RN E said interventions for risks or illnesses should be care planned. Interview with ADON P on 10/14/24 at 4:50 PM revealed ADON P said the residents that were in the secured unit, should have that care planned. ADON P said being in the secured unit, was the intervention for the residents that had the diagnosis of dementia or Alzheimer's and were at risk of elopement/wandering or with exit seeking behaviors. ADON P said she was not sure why the care plans did not reflect the secured unit for Resident #2, Resident #3, and Resident #10. ADON P said there was a wandering evaluation they had to fill out and if they filled out the bottom section, then it would delete or resolve the care plan for the risk of elopement/wandering. ADON P said they had to leave the bottom section blank or else the care plan would resolve or update. ADON P said the care plans should include the secured unit. 675162 Page 3 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Interview with MDS N on 10/15/24 at 11:15 AM revealed MDS N said they completed assessments quarterly and updated the care plans. MDS N said care plans were also updated as needed if the resident had a significant change or new interventions were implemented. MDS N said different staff sometimes updated different sections of the care plan. MDS N said they had to complete a new wandering tool for all residents. MDS N said the SWs and the ADONs completed the evaluations. MDS N said there was a question at the bottom that asked if the residents were still wandering or something to that affect. MDS N said if they checked off the questions or put yes, then it threw off the assessment or care plan. MDS N said as of today, they had already looked at all of care plans and updated to show the secured unit. MDS N said maybe the staff did not know how to complete the forms correctly so the care plans did not reflect the secured unit. MDS N said as of yesterday , 10/14/24, Resident #2, Resident #3, and Resident #10's care plans did not reflect the secured unit or the risk of elopement/wandering. MDS N said they checked all the residents that were in the secured units and ensured the care plans indicated the secured unit and the reason or risk of elopement/wandering. MDS N said placement in the secured unit was for their safety, to keep a closer eye on them and distracted with more activities. MDS N said the staff knew which residents resided in the unit. MDS N said it was still important to have these interventions care planned so the staff knew what pertained to the resident and how they were going to care for them. Interview with SW U on 10/15/24 at 11:40 AM revealed SW U said she assisted with the care plans. SW U said back in July 2024, the company had a new wandering evaluation and the system triggered for all residents to be evaluated with the new form. SW U said she and ADON P worked on the evaluations for the female secure unit. SW U said whoever completed the forms, she thought was doing them right, but maybe not. SW U said she helped complete a few. SW U said if the wandering evaluation was filled out a certain way, then it would resolve the care plan and it removed the wandering or elopement risk from the care plan. SW U said the care plans did not have the secure unit noted because the wandering evaluations were done incorrectly. SW U said the wandering evaluation and the secure unit evaluations were done quarterly. SW U said the care plans did not reflect the residents that were at risk of elopement if the evaluations were filled in wrong. SW U said Resident #2, Resident #3, and Resident #10 were placed in the unit because they were at risk of elopement, exit seeking, or wandering and had the diagnosis of dementia or Alzheimer's. SW U said it was important to include the secure unit in the care plan so that staff were aware of the risk of elopement, exit seeking, or wandering. SW U said if the risk of elopement, wandering, or the fact that they were placed in the secure unit was not care planned, then staff might not know and they would be at risk of leaving. SW U said the staff were aware of who resided in the secure unit and those residents were also added to the elopement binder which ensured staff were familiar with their behaviors. SW U said Resident #10 had been evaluated before she was sent to the hospital and was noted to have a health decline that indicated she would soon transition out of the secured unit. SW U said before Resident #10 was discharged to the hospital on [DATE], she was in the secure unit and would have needed the secure unit and risk of wandering to be care planned. Interview with DON on 10/15/24 at 2:00 PM revealed the DON said the corporate company came out with a new wandering form. The DON said they completed the form for all residents but first focused on the residents in the secured units. The DON said if they did not check off one of the last 3 questions, if it was left blank, then it automatically resolved the care plan for that section. The DON said the forms were not filled out correctly so the system resolved some of the care plans that should not have been resolved. The DON said SW U and ADON P completed the wandering evaluations for the female secure unit. The DON said they were under the impression that they did not have to click on implemented, re-evaluated, or 675162 Page 4 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some updated, because then it would have updated the current care plan. The DON said since they left that blank, it resolved on the care plan. The DON said Resident #2, Resident #3, and Resident #10 did not have the risk of elopement or wandering and placement in the secure unit care planned. The DON said their risk and placement in the secure unit should be care planned to ensure staff were aware of how to care for the residents, specifically to each resident. The DON said audited and reviewed all residents' care plans for accuracy and they now reflected the secure unit accurately. The DON said they unresolved and updated all the care plans. The DON said the residents were not injured and did not have any adverse effects as a result of the risks or secure unit not being care planned. The DON said the residents would be at risk of the staff not knowing how to care for them appropriately as they would not be aware of the secure unit placement or the reason. The DON said they went over the form and showed the staff how to properly complete them. The DON said they also started an in-service regarding the wandering evaluation and care plans. Interview with ADM on 10/15/24 at 3:00 PM revealed the ADM said in July 2024, the facility had to do new assessments for the wandering evaluation. The ADM said when the assessments asked the questions, and the staff answered a certain way, there was a glitch that caused the care plans to resolve which removed the secure unit or risk of elopement in the care plans. The ADM said this was not just for their facility, but companywide, so they informed their corporate managers. The ADM said they completed an in-service with the managers and reviewed all the care plans yesterday. The ADM said because the residents were in the secured unit, that did not mean that the issue was resolved, but rather the secure unit was the intervention implemented. The ADM said the staff completed the assessments incorrectly which triggered the resolution of the care plan. The ADM said when they entered the incorrect answer or no answer, then it generated over to the care plan incorrectly. The ADM said they looked at everyone's care plan and corrected them. The ADM said they also started the in-services with managers. The ADM said on admission, the nursing department started the wandering assessment and then it went to social services so it was a team effort and everyone would be in-serviced. The ADM said she verified Resident #2, Resident #3, and Resident #10, who were placed in the secure unit, had the secure unit and risk of elopement, wandering, or exit seeking behaviors missing, but have been fixed. The ADM said the residents that were in the unit were at risk of elopement and the secure unit was one of the interventions. The ADM said that should have been care planned. The ADM said the importance of having the interventions in the care plan was to ensure the residents were safe and staff knew how to care for them. Record review of Comprehensive Care Plans Policy date implemented 10/24/22 revealed: Policy: It is the policy of this facility to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the resident's comprehensive assessment. 3.a. The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 5. The comprehensive care plan will be reviewed and revised by the interdisciplinary team after each comprehensive and quarterly MDS assessment. 675162 Page 5 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0687 Provide appropriate foot care. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to provide foot care and treatmenet to maintain mobility and good foot health for 1 (Resident #2) of 1 residents reviewed for foot care services. Residents Affected - Few The facility failed to ensure Resident #2 received podiatry services as Resident #2's toenails were long (about an inch overgrown), not trimmed, and Resident #2 was not treated by the in-house podiatrist during their last visits. This failure could place residents at risk of potential negative outcomes related to foot health including pain, discomfort, poor foot hygiene, or a decline in residents' physical condition. The findings included: Record review of Resident #2's file dated 10/09/24 reflected an [AGE] year-old female with an original admission date of 06/04/24. Her diagnoses included: unspecified dementia, type 2 diabetes, hypertension, mood disorder, delusional disorders, depression, insomnia, need for assistance with personal care, abnormalities of gait and mobility, cognitive communication deficit, and adult failure to thrive. Record review of Resident #2's MDS dated [DATE] reflected a BIMS score of 3 (severe cognitive impairment). Resident #2 required partial/moderate assistance (helper does less than half the effort) for personal hygiene (combing hair, shaving, applying makeup, washing/drying face, and hands), was dependent (helper does all of the effort) to shower/bathe (bathe, wash, rinse, and dry self), required substantial/maximal assistance (helper does more than half the effort) for lower body dressing (dress/undress below the waist), and required substantial/maximal assistance (helper does more than half the effort) for putting on/taking off footwear (put on/take off socks and shoes/footwear). Record review of Resident #2's care plan dated 10/09/24 reflected Resident #2 was dependent for meeting emotional, intellectual, physical, and social needs related to dementia. Date initiated: 06/10/24. Resident #2 had an ADL self-care performance deficit related to dementia. Date initiated: 06/20/24. Interventions included: Resident #2 required substantial/maximal assistance for lower body dressing. Resident #2 required partial/moderate assistance for personal hygiene. Resident #2 required substantial/maximal assistance for footwear. Resident #2 was dependent for shower/bathe. Resident #2 required total assistance by 1 staff with bathing/showering per resident needs and as necessary. Resident #2 required extensive assistance by 1 staff to dress. Resident #2 required skin inspection by skilled nurse weekly/PRN to observe for redness, open areas, scratches, cuts, bruises, and report changes to the MD. Monitor/document/report PRN any changes, any potential for improvement, reasons for self-care deficit, expected course, declines in function. Record review of Resident #2's order summary dated 10/14/24 reflected an order for the in-house podiatrist to treat and evaluate. Order date: 08/10/24. Record review of Resident #2's pain evaluation dated 10/14/24 reflected no pain or discomfort to bilateral (both) feet. Record review of Resident #2's weekly skin evaluation dated 10/14/24 reflected Resident #2 needed 675162 Page 6 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few foot/nail care. Previous skin evaluations dated 09/01/24-10/01/24 did not reflect needing foot/nail care or injuries to bilateral feet. Record review of Resident #2's progress notes dated 08/01/24-10/14/24 reflected there were no notes found that staff attempted to obtain the consent for the podiatrist or that Resident #2 was added to the podiatrist's visit list. Interview with Resident #2 on 10/14/24 at 1:55 PM revealed Resident #2 said her toes and feet did not hurt. Resident #2 said she walked without issue. Resident #2 said she showered and cut her toenails on her own. Resident #2 said she left her toenails too long. Resident #2 said she wanted to cut her toenails. Observation of Resident #2 on 10/14/24 at 2:00 PM revealed Resident #2 was not wearing shoes and her toenails were visible. Resident #2's toenails were about an inch longer than the nailbed. Interview with CNA A on 10/14/24 at 4:15 PM revealed CNA A said she assisted Resident #2 to shower/bathe and Resident #2 did not bathe on her own. CNA A said she assisted Resident #2 to change and get dressed. CNA A said she was not sure if Resident #2 was diabetic. CNA A said she had not noticed if Resident #2's toenails were too long. CNA A said Resident #2 did not cut her own toenails. CNA A said Resident #2 had not complained about her feet or toes hurting. CNA A said she was not sure if the podiatrist would see Resident #2, but the nurse knew that information. Interview with LVN T on 10/14/24 at 4:25 PM revealed LVN T said she had not noticed if Resident #2's toenails were too long. LVN T said Resident #2 had not complained of pain or discomfort. LVN T said the CNAs had not mentioned that Resident #2's toenails were too long. LVN T said Resident #2 had the diagnosis of diabetes and the nurses could cut her toenails. LVN T said the residents were usually referred to the podiatrist, especially when the resident was diabetic. LVN T said she was not sure if they had gotten the consent for the podiatrist or if Resident #2 was added to the podiatrist list. LVN T said the podiatrist came every month or so. LVN T said she was not sure when was the last time the podiatrist saw residents. Interview with ADON P on 10/14/24 at 4:45 PM revealed ADON P said she saw Resident #2's toenails and agreed that her toenails were too long. ADON P said she asked Resident #2 if her toes or feet were hurting or if she had trouble walking and Resident #2 denied any pain or discomfort. ADON P said she asked Resident #2 if she wanted her toenails cut and Resident #2 said yes. ADON P said Resident #2 was able to ambulate without issue and Resident #2 said her shoes did not bother her toes or fit too tight. ADON P said she had not been informed that Resident #2's toenails were too long. ADON P said she was not sure if they had gotten consent for the podiatrist or if they had attempted to get consent from the family. ADON P said SW U was good about obtaining consents when needed. ADON P said she was not sure what the issue was or what happened that Resident #2's toenails were not addressed. Review of Resident #2's progress notes revealed: On 10/14/24 at 10:02 PM, documented by LVN T: Foot/nail care to bilateral feet provided to resident, nails trimmed and cleaned under surface of the nails, skin intact between toes, applied moisturizing lotion, tolerated. On 10/15/24 at 8:21 AM, documented by the SW: 675162 Page 7 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0687 The resident's RP verbally consented to the resident being referred to the podiatrist. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #2's podiatrist consent dated 10/15/24 reflected verbal consent obtained for a podiatry visit from the RP. Residents Affected - Few Interview with SW U on 10/15/24 at 11:40 AM revealed SW U said the nurses told her if they needed a consent form for something specific. SW U said if the resident had diabetes, then the podiatrist had to see them. SW U said she usually asked the nurses if they needed any consents done before the podiatrist was going to do his rounds. SW U said the nurses never told her she needed to get a consent for Resident #2. SW U said the podiatrist last rounded on 10/10/24 and before that, the podiatrist was at the facility the last week of September 2024. SW U said the podiatrist did not have a set schedule but the visits depended on which residents needed to receive treatment. SW U said LVN T cut Resident #2's toenails yesterday , 10/14/24, so Resident #2 did not have to wait for the podiatrist. SW U said the nurses could cut the toenails but they had to be very careful. SW U said she visited Resident #2 yesterday and she did not see her toenails because she was wearing shoes. SW U said Resident #2 was walking in the hallway and did not complain of feet/toe pain. Observation of Resident #2 on 10/15/24 at 1:30 PM revealed Resident #2's toenails were trimmed and filed to about 0.5 cm above the nailbed. Interview with RN E on 10/15/24 at 1:40 PM revealed RN E said she had not seen Resident #2's toenails. RN E said the CNAs had not mentioned that Resident #2's toenails were too long. RN E said she was under the impression that the podiatrist would see Resident #2. RN E said the podiatrist came 2 weeks ago and did not see Resident #2. RN E said she was not sure if the podiatrist was pending to come back to see Resident #2 or had pending residents. RN E said LVN T did cut Resident #2's toenails yesterday, and LVN T applied cream. RN E said SW U got consent from the family for the podiatrist but RN E could also get the consent. RN E said she was not sure what happened after Resident #2 got the order on 08/10/24 for the podiatrist to treat her in-house. RN E said she did not know if the consent was obtained or not. RN E said Resident #2 had not complained of pain or discomfort to her toes or feet. RN E said the nurses were able to cut the toenails for the residents that have diabetes. RN E said the CNAs could not cut their toenails. RN E said Resident #2's toenails were currently trimmed and filed without issue. Interview with the DON on 10/15/24 at 2:00 PM revealed the DON said Resident #2 had her toenails very long. The DON said it was brought up to their attention yesterday by the investigator. The DON said LVN T was able to trim Resident #2's toenails yesterday. The DON said the podiatrist emailed the DON to confirm the visit and to check if any residents needed to be added. The DON said she forwarded to the departments and asked if any resident needed to be added. The DON said if anyone needed to be added, they would have gotten the consent form and everything ready. The DON said SW U and the nurses worked well to obtain consents as needed but the consent was not obtained for Resident #2. The DON said Resident #2 was missed. The DON said it was a team effort and everyone failed to identify the concern. The DON said CNAs did shower Resident #2 and had the opportunity to see the toenails were very long to let the nurse know. The DON said the nurses could have at least trimmed the toenails. The DON said since Resident #2 was diabetic, the CNAs could not cut her toenails. The DON said at least the facility would have known and they would have added Resident #2 to the podiatrist list. The DON said if the toenails were not too thick, then the nurse could trim and file the toenails, which was what LVN T did yesterday. The DON said the podiatrist would visit for an emergency if there was something urgent that the nurses could not take care of. The DON said Resident #2 was not injured and was not in pain, but the overgrown toenails could have caused Resident #2 discomfort. The DON was 675162 Page 8 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0687 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few shown the photo of Resident #2's toenails and the DON agreed that Resident #2's toenails were very long. The DON said they started an audit and in-service so that a resident's foot care was not missed again. The DON said she did not find a policy specific for foot care but the ADLs policy addressed grooming which included nail care. Interview with the ADM on 10/15/24 at 3:00 PM revealed the ADM said Resident #2's toenails were just missed. The ADM said the nurse assessed Resident #2 and Resident #2 did not refuse to get her toenails cut. The ADM said they ensured Resident #2 was not in any pain, completed the skin assessment and pain assessment. The ADM said they obtained the consent and put Resident #2 on the podiatrist list. The ADM said LVN T trimmed Resident #2's toenails yesterday. The ADM said Resident #2 had not previously refused to have her toenails cut. The ADM said Resident #2's toenails fell through the cracks. The ADM said they were going to work on an audit tool to prevent another resident's foot care from being missed. The ADM said Resident #2 had no adverse effects. The ADM said the nurse could cut the toenails even if the resident had diabetes as long as the nurse was very careful. The ADM said the podiatrist may take months to come in and they did not want Resident #2 to wait so they had LVN T trim her toenails. The ADM said Resident #2 continued to be monitored and she was doing well. Record review of Activities of Daily Living (ADLs) Policy date implemented 05/26/23 revealed: Care and services will be provided for the following activities of daily living: 1. Bathing, dressing, grooming (including nail care), and oral care. 675162 Page 9 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0925 Make sure there is a pest control program to prevent/deal with mice, insects, or other pests. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for pest control. Residents Affected - Some The facility failed to ensure the current pest control program was effective to eradicate and contain common household pests including roaches in multiple areas including resident rooms, hallways, and dining room. This failure could place all residents at risk of insect borne illnesses, to live in an uncomfortable/non-homelike environment free of pests, and a decreased quality of life. The findings included: Interview with Resident #1 on 10/09/24 at 12:45 PM revealed Resident #1 said she had seen roaches. Resident #1 said the last time she saw a roach was about a month ago, in her room, on the wall, and it was alive. Resident #1 said she told the staff but did not know if the roach was found or killed. Resident #1 said she did not have any injuries related to roaches, bugs, or other pests. Interview with Resident #2 on 10/09/24 at 1:05 PM revealed Resident #2 said she had seen a roach in her room, on top of the dresser. Resident #2 said it was last week and it was alive. Resident #2 said she told the staff and they were able to kill it. Resident #2 said she did not remember which staff. Resident #2 said the staff cleaned her dresser and room after that. Resident #2 said she did not have any injuries related to roaches, bugs, or other pests. Interview with CNA A on 10/09/24 at 2:05 PM revealed CNA A said she had seen roaches in the facility and it was an issue. CNA A said she was not sure if there was any fumigation done. CNA A said she had seen the roaches in the rooms and hallway of the 400 hall. CNA A said she documented the sightings in the log which was what she was supposed to do when she saw a roach or bug. CNA A said she did not remember what day that happened , but she had not worked at the facility very long. CNA A said if the roach was dead, she picked it up. CNA A said housekeeping cleaned the halls and rooms every day . Interview with HK S on 10/09/24 at 2:40 PM revealed HK S said housekeeping staff cleaned the rooms every day, including the weekend. HK S said housekeeping also disinfected the bedframe, furniture, chairs, etc. HK S said pest control was taken care of by the maintenance department. HK S said if they saw a roach, ants, or other pests, they documented in the log for the pest control. HK S said he was not sure how often the pest control company visited, maybe weekly or monthly. HK S said housekeeping ensured to clean the rooms so that there was no food, crumbs, or anything hidden to avoid pests. Interview with MN D on 10/09/24 at 3:00 PM revealed MN D said the pest control company serviced the building once a month. MN D said if they needed to be serviced more often, he called the company and the company came out the following day. MN D said they contracted with the company and called them if they needed more services if they saw an increase in pests or an issue came up. MN D said there was a sightings log kept at the nurse's station and staff knew to document any sightings on the log. MN D said the pest control company looked at that log and knew where to focus on during their visit. MN D said months ago, they had more of an issue with roaches, so the company came out more 675162 Page 10 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some frequently to fumigate and service the building. MN D said recently, there had been 1 or 2 roaches, here and there, and it was not an issue or infestation. MN D said the logs noted mostly isolated incidents. MN D said the roaches have been noted on the floors, not on the residents' beds or belongings. Interview with CNA B on 10/14/24 at 11:20 AM revealed CNA B said she saw roaches in the residents' rooms in the 400 hall. CNA B said she saw 1 roach at a time, crawling on the floor. CNA B said if she saw a roach, she documented in the log. CNA B said she had seen the fumigation company within the next few days. CNA B said she did not remember what day that was. CNA B said the housekeeping staff also disinfected the rooms. Interview with CNA C on 10/14/24 at 11:45 AM revealed CNA C said she saw roaches in the hallway, but the pest control company fumigated. CNA C said she did not remember what day that happened. CNA C said she was not sure how often the pest control came out but she saw them every few weeks. CNA C said whenever she saw a roach, she told the nurse and the nurse input the information in the system for a work order to the maintenance. CNA C said they also documented in the binder at the nurse's station to log any roaches or ants. Interview with Resident #4 on 10/14/24 at 12:20 PM revealed Resident #4 said she saw a roach this morning in the 200 hallway . Resident #4 said the roach was alive and it ran away. Resident #4 said she was not sure if the staff saw the roach or tried to kill it. Resident #4 said she did not tell anyone about the roach but hoped it would not go to her room. Resident #4 said she had not seen roaches or bugs in her room before. Resident #4 said she did not have any injuries related to roaches, bugs, or other pests. Interview with Resident #9 on 10/14/24 at 12:40 PM revealed Resident #9 said she saw a roach in the 300 hallway , but she did not remember when. Resident #9 said when she saw the roach it was alive and it ran away. Resident #9 said she had seen some men spray the hallways but did not remember when. Resident #9 said she did not have any injuries related to roaches, bugs, or other pests. Observation on 10/14/24 at 1:45-1:50 PM revealed a dead roach in the 300 hall and a dead roach in the 400 hall. Interview with LVN G on 10/14/24 at 2:50 PM revealed LVN G said he saw a roach every now and then. LVN G said he usually saw it on the floor, in the hallway, or by the nurse's station. LVN G said he added it to the pest control binder. LVN G said he saw the man fumigate with the tank. LVN G said he was not sure if the man sprayed every room but the man went into different parts of the building. LVN G said there were no indications that residents were getting bit by ants or any kind bug/pest. Interview with CNA H on 10/14/24 at 3:10 PM revealed CNA H said the families of residents had sometimes reported seeing pests like roaches. CNA H said she had seen the fumigation come out to fumigate. CNA H said the residents ate in their rooms and as much as the staff tried to clean, there was crumbs or food left. CNA H said she had seen roaches, dead and alive. CNA H said the staff used the 300 hall exit to throw out trash because the dumpsters were nearby. CNA H said it was easier for pests to be around those areas. CNA H said when she saw a roach, she told the nurse and the nurse reported it. Interview with LVN J on 10/14/24 at 3:30 PM revealed LVN J said there were roaches in the hallway. LVN J said the roaches were usually small and dead or alive. LVN J said staff were supposed to kill 675162 Page 11 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0925 the roach if it was not dead and document in the book. LVN J said they also disinfected the area. Level of Harm - Minimal harm or potential for actual harm Interview with SW U on 10/24/24 at 3:45 PM revealed SW U said she logged the sighting in October 2024 for pests. SW U said on 10/01/24, she saw 2 roaches in her office, a small one and a big one, she killed them and logged it in the book. SW U said on 10/01/24, she also logged sightings for other staff. SW U said she did not remember which staff but the staff saw a roach in room [ROOM NUMBER] and a little worm in room [ROOM NUMBER]. SW U said on 10/09/24, she was walking in the hall and saw a spider going down from the middle of the door frame with its web, it was gliding down and the CNA got it and killed it. SW U said there were other roaches after those sightings, this past week. SW U said from what she understood, the fumigation company did not fumigate each room because if they did the residents could not be in the rooms. Residents Affected - Some Interview with MN D on 10/14/24 at 3:55 PM revealed MN D said there were more sightings after 10/09/24. MN D provided an updated log. MN D said the last time the pest control company serviced the building was on 09/26/24. MN D said he called the pest control company and the company was supposed to service the building on Friday, 10/11/24, but the company was running behind. MN D said the company was supposed to service the building this week. MN D said if the residents voiced concerns during resident council regarding maintenance, he was not informed. MN D said he just based things off the binder (sightings log). MN D said when the pest control company came out, they did not fumigate every room. MN D said they fumigated the main entrances, the main doors of each hall, and the rooms or areas noted on the sighting logs. Interview with Resident #6 on 10/14/24 at 4:05 PM revealed Resident #6 said he had concerns regarding roaches. Resident #6 said he saw roaches in his room and the roaches ran into the wall cracks (corners) of his room. Resident #6 said he had seen a lot of roaches on the floor and on the table. Resident #6 said that happened about a week ago. Resident #6 said he told staff but did not remember who. Resident #6 said he did not think his room was fumigated or sprayed. Resident #6 said he did not know if anything was done regarding his concerns. Resident #6 said he did not have any injury related to roaches, bugs, or other pests. Interview with LVN T on 10/14/24 at 4:25 PM revealed LVN T said she had seen roaches in the 400 hallway . LVN T said the roaches came out more during the nighttime. LVN T said if they saw a roach, they inputted the information for the maintenance work order and documented in the sighting log. LVN T said she saw the fumigation company spray but maybe the building was just old. Observation on 10/14/24 at 10:30 PM revealed the same dead roach in the 300 hall noted. Interview with CNA K on 10/14/24 at 10:45 PM revealed CNA K said she saw roaches come out at night and the roaches were alive. CNA K said she killed the roaches or tried to kill them and reported it to the nurse. CNA K said the nurse reported it on the logbook. CNA K said she had seen roaches in the residents' rooms. CNA K said the residents had food and snack in their rooms. CNA K said the residents wanted to have those items and staff could not throw them away or the residents could become upset. Observation on 10/14/24 at 11:00 PM revealed the same dead roach in the 400 hall noted. Interview with CNA L on 10/14/24 at 11:15 PM revealed CNA L said there were roaches at night and the roaches were everywhere. CNA L said the roaches were on the floor, on the residents' beds, or the roaches were even the flying ones. CNA L said the residents were asleep and the roaches were on the 675162 Page 12 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some residents. CNA L said if she saw a roach, she told the nurse. CNA L said she saw the residents trying to kill the roaches. CNA L said she redirected the residents and tried to kill the roach herself. CNA L said she did not remember which residents or what days this happened. CNA L said the residents were not injured or hurt but it was not okay for the roaches to be around the residents. Observation on 10/14/24 at 11:25 PM revealed an alive roach was on the counter in the small dining room. The roach ran back into the cabinet and staff did not find it. Interview with LVN M on 10/14/24 at 11:30 PM revealed LVN M said she saw roaches mostly when she worked at night. LVN M said she also saw roaches randomly during the day. LVN M said she saw roaches in the rooms, in the hallways, both dead and alive. LVN M said she had killed roaches before. LVN M said she also documented in the pest control book. Interview with AD I on 10/15/24 at 10:50 AM revealed AD I said if there were any concerns brought up during resident council meetings, she would bring up the concerns to the specific department in charge of resolving the issue. AD I said if there was a concern for maintenance regarding rodents or roaches, she would have told MN D. AD I said she was sure she told MN D about the concern brought up in the September 2024 meeting. AD I said she had seen some roaches here and there in the hallway, mostly dead. Interview with CNA O on 10/15/24 at 12:45 PM revealed CNA O said she saw roaches at the facility. CNA O said sometimes the roaches were dead and sometimes alive. CNA O said if the roach was alive, she tried to kill it but sometimes it was too fast. CNA O said if the roach was dead, she picked it up and threw it away. CNA O said she was not sure if they had to report or document anywhere about the roaches. Interview with the DON on 10/15/24 at 2:00 PM revealed the DON said for the pest control visits, the ADM and maintenance department oversaw that service. The DON said it was a team effort to ensure they documented any pest sightings, cleaned, and disinfected the areas. The DON said the managers did environmental rounds and if they saw anything, whether it was in the hallways or the rooms, they ensured to document in the book. The DON said they discussed any issues with housekeeping, maintenance, and managers. The DON said the 300 hall exit door was used for the trash, the service door in the back also used, and constant in and out opening and closing the doors, so all that would not help with the issue of pests. The DON said as far as pest control extra visits and such, it would be up to the ADM to get those approved. The DON said they instructed staff to log any sightings in the book for pest control so that the pest control company knew where to go in the building. The DON said she believed the pest control came out every 2 weeks but was not exactly sure. The DON said there were no injuries resulting from roaches, ants, or pests. The DON said if there was no effective pest control, the residents would be at risk of harm, such as insect bites. Interview with the ADM on 10/15/24 at 3:00 PM revealed the ADM said she thought the pest control company came out every couple of weeks but she was not sure. The ADM said the company came out as needed or if they saw an issue. The ADM said the company did not always come in the same day or the next day when they called them. The ADM said the company sometimes took longer to come in which was an issue. The ADM said the company they used was the pest control company that their corporation was contracted with. The ADM said she believed the service provided was enough or effective. The ADM said she was not sure if the temperature or what caused more roaches than other times. The ADM said some residents did not like their rooms very cold, or the temperatures outside varied and affected the roaches such as if it rained or different weather. The ADM said they told staff to report it in the 675162 Page 13 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some pest control log so that if they saw multiple things, then they had the pest control company come in more times. The ADM said the pest control company fumigated the rooms that were on the logs, not all rooms. The ADM said if they put down the 400 hall, the company was not going to fumigate the entire 400 hall. The ADM said they needed to document which rooms to target, not just generalized. The ADM said they had done it in the past, if they saw a trend, where they asked for every room to be fumigated, but they had to document 401, 402, 403, etc. The ADM said they instructed staff to do that if that was the case. The ADM said they had not done that or asked for every room to be fumigated recently. The ADM said if the staff saw a roach, they should have killed it if it was alive, picked it up, and documented in the pest control. The ADM said that was the best way to prevent it from continuing. The ADM said if the roach was dead, the staff should have picked it up, not just left it there on the floor, and logged it in the book. The ADM said it was a team effort, not just housekeeping. The ADM said if there were any concerns brought up in the resident council meetings, then the issue was communicated with the specific department. The ADM said there was no facility policy for pest control, but she provided a copy of the pest control program specifications. The ADM said there were no residents with injuries or adverse effects resulting from roaches or pests concerns. Record review of Resident council meeting minutes reviewed for July-September 2024 revealed: For the September 2024 council meeting: Resident #6 had a maintenance related concern that roaches came out of wall trim. Record review of Pest Control Visits revealed: Dated 07/29/24 reflected sightings: large cockroaches reported in front nurse's station, housekeeping room in 300 hall, and therapy room. There were no sightings during service. Inspected and treated common areas, kitchen, laundry, offices, storage room, restrooms, boiler room, and maintenance area. Therapy room and housekeeping room in 300 hall also inspected. Inspected and treated perimeter of the building. Dated 08/29/24 reflected sightings: ants. There were no sightings during service. Inspected and treated common areas, kitchen, laundry, offices, storage room, restrooms, boiler room, and maintenance area. Inspected rooms 306, 305, 301, 207, 102, and 607. Inspected and treated perimeter of the building. Dated 09/19/24 reflected emergency service for ants. Sightings: flying ants. Found 20 different fire mounds, treated with extinguish and used demand at entry points. Dated 09/26/24 reflected sightings: fire ants. There were no sightings during service. Inspected and treated common areas, offices, bathrooms, break rooms, laundry rooms, kitchen, nurse's stations, and hallways. Inspected and treated perimeter of the building. Record review of the pest sightings log for 05/01/24-10/14/24 revealed: Pests noted in different areas of the building (roaches in 400, 600, 300 halls, rooms 617, 618, 619, 609, 611, dining room, copy room, roach in 400 hall entrance, ants in room [ROOM NUMBER], flying roach in room [ROOM NUMBER], roach in room [ROOM NUMBER], bug in room [ROOM NUMBER], bug in room [ROOM NUMBER], bug in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants by 600 hall nurse's station, roaches in 300 hall, roach by front nurse's station, roach in activity office, roaches in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants in room [ROOM NUMBER], 675162 Page 14 of 15 675162 10/15/2024 Briarcliff Nursing and Rehabilitation Center 3201 N Ware Rd McAllen, TX 78501

F 0925 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants in room [ROOM NUMBER], roach on wall, roach in room [ROOM NUMBER], ant in room [ROOM NUMBER], ants in room [ROOM NUMBER], ants and roaches in room [ROOM NUMBER], ants in room [ROOM NUMBER], 2 roaches in SW U's office, roach in room [ROOM NUMBER], worm in room [ROOM NUMBER], spider in room [ROOM NUMBER], roach in room [ROOM NUMBER], spider web in room [ROOM NUMBER], roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], ants in room [ROOM NUMBER], roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], roaches in room [ROOM NUMBER], flying roaches in room [ROOM NUMBER], roaches all over 400 hall) and all halls noted. Not specific to one area. Roaches, ants, and other bugs reported 43 times since May 2024 by various staff. Record review of Pest Control Company Services Program Specifications dated 04/01/17 revealed: Service Frequency: During the regular service, the service specialist will perform services according to a specified service interval as detailed below. Interior crawling insect and rodent programs: every month Interior flying insect program (if applicable): every month Exterior crawling insect and rodent programs: every month Service log sightings: each service Areas to be serviced: food service/dietary area, food service storage areas, dining areas, activity areas, office/administrative areas, public access areas, clean/soiled utility areas, bath/shower areas, health/beauty areas, gift shop/common areas, laundry/housekeeping areas, and mechanical/boiler room areas. Availability: 24 hours/day 7 days/week Emergency service: Personnel area on call 24 hours a day, 7 days a week. Should the need arise, calls from the facility requesting assistance to a pest issue will be responded to within 30 minutes of the call being received, and an on-site visit will be conducted within 24 hours. There is no charge for extra service requests for standard covered pests, or other pests covered by agreement. 675162 Page 15 of 15