Health inspection·November 20, 2025

F 0656 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 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 interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop a care plan to include Resident #1's behaviors and interventions. This failure could place residents at risk of not receiving safe and appropriate care. The findings include: Record review of Resident #1's face sheet, dated 11/20/25, revealed an [AGE] year-old male who was initially admitted to the facility on [DATE]. Resident #1 had diagnoses which included: vascular dementia (a decline in thinking skills caused by conditions that damage blood vessels and reduce or block blood flow to the brain), moderate with mood disturbance, obstructive (blockage that prevents urine from flowing out of the body) and reflux uropathy (urine flows backwards from the bladder) , unspecified, and retention of urine (inability to completely empty the bladder), unspecified. Record review of Resident #1's quarterly Minimum Data Set assessment, dated 09/29/25, revealed Resident #1 had a BIMS score of 03, which indicated he was severely cognitively impaired. Resident #1's MDS did not indicate any behaviors. Record review of Resident #1's care plan retrieved on 11/14/25 did not include any documentation related Resident #1's behavior of urinating in trash cans or on the floor in his room. Record review of Resident #1's care plan retrieved on 11/20/25 included a problem of, [Resident #1] has episodes of urinating in inappropriate areas (wastebasket, floor) and is at high risk for falls related toincontinence and wet floor hazards. With an initiated date of 11/19/25. During a record review and interview with the DON on 11/20/25 at 5:07pm she stated Resident #1 had a behavior of urinating in the trash bins in his room and restroom. The DON stated Residents #1's behavior of urinating in the trash cans started about 6 months prior to November 2025. The DON stated staff had never physically seen Resident #1 urinating in the trash cans, but they had found yellow liquid in the trash cans that smells. The DON stated herself, SW A and ADON B were responsible for adding these behaviors to Resident #1's care plan. The DON stated she had been aware of the behavior previously and had discussed these behaviors with both SW A and ADON B. The DON stated SW A had told her the behavior had been care planned. The DON stated this kind of behavior should be included on the residents care plan to make sure everyone was aware and to make sure they were checking the trash liners and taking them out. The DON stated she had reviewed Resident #1's care plan after this surveyor asked questions on 11/19/25 regarding Resident #1's behaviors and did not see his behaviors care planned and stated they added Resident #1's behaviors afterwards on 11/19/25. The DON stated it was important to include behaviors on the care plan because it was the plan of care and communication from staff to staff. The DON stated the interdisciplinary team reviewed care plans for all required information including behaviors quarterly and as needed. The DON Page 1 of 2 675162 675162 11/20/2025 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 - Few stated they did this by reviewing 24 hour reports and 72 hour reports to review for any documented behaviors from staff and then determined what the behavior was and have it reflected on their care plan so everyone was aware and would be aware of the interventions to try to minimize those behaviors. The DON stated both her and SW A have been trained over developing a care plan and what should be included. The DON stated the facility policy regarding care plans stated it should include residents behaviors and changes should be made as needed ad were on going. The DON stated this policy was not followed due to Residents #1's care plan not being updated. The DON stated not including residents behaviors on their care plan could impact the communication among direct care staff. During an interview with SW A on 11/20/25 at 5:59pm SW A stated from what she was aware of Resident #1 did not urinate outside of the restroom and stated based off her previous interviews Resident #1 always urinated in the restroom and stated that was the room she checked and had never seen urine outside of the restroom. SW A stated Resident #1 may miss the toilet and get urine on the floor in the restroom but that was it. SW A stated nothing had been reported to her that it was a behavior Resident #1 had. During an interview with ADON B on 11/20/25 at 7:32pm stated you could smell urine and see it in the trash cans but stated she had never seen him physically do it. ADON B stated she did not recall when Resident #1 started urinating in the trash can but states leadership had been aware and had discusses it in the morning meetings and had discussed it with both the DON and SW A. ADON B stated no one had seen Resident #1 urinate in the room and never reported seeing it either but had only found urine in the trash can. ADON B stated generally SW A was responsible for adding behaviors such as urinating in the room on the care plans and stated ultimately everyone was. ADON B stated she reviewed Residents #1's care plan on 11/19/25 after this surveyor spoke to staff about the behavior and ADON B stated she had not seen anything on there regarding urinating. ADON B stated she did not know why the Resident #1's behavior was not on his care plan. ADON B stated from what she was aware of SW A had reviewed the care plan previously and had said it was on there, ADON B stated it was oversight. ADON B stated it was important for behaviors to be on the care plan so that staff would be aware of how to address, redirect the behaviors and how to implement intervention. ADON B stated the interdisciplinary team would review and monitor the care plans to ensure they had all required information including behaviors and stated they did this during their morning meetings and meetings at 3:30pm and stated they would go over anything new and would update the care plan and add interventions. ADON B stated staff had been trained over developing the care plan and what should be included. ADON B stated without looking at it she could not recall what the facilities policy stated in regards to including behaviors on the care plan. ADON B stated she felt staff did not follow their facility care plan policy when it came to Resident #1. ADON B stated not including residents behaviors on their care plan could negatively impact them because staff would not be able to implement the interventions. Record review of facility in-service training report dated 01/31/25 that covered comprehensive care plans reflected, the DON, SW A and ADON B had all received the training. Record review of the facility's policy titled, Comprehensive Care Plans with an implemented date of 10/24/22 stated, The comprehensive care plan will describe, at a minimum, the following:The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being. 675162 Page 2 of 2