Inspection·November 21, 2025

F 0842 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete the facility had recently changed assessment forms as the Skilled Evaluation form was complicated and too long. The DON stated the failure to ensure accuracy of documentation could place the residents at risk for missed assessment that could result in harm to residents. An interview on 10/08/2025 at 3:30 p.m. with the Administrator revealed that she expected nursing staff to follow all protocols and procedures for accurate documentation for all residents. The Administrator stated that poor documentation reflects on the credibility of nursing care and facility overall. Record review of policy and procedures titled Charting and Documentation, Revised October 2021 revealed medical records should be complete and accurately document residents' medical condition. Event ID: Facility ID: 675666 If continuation sheet Page 2 of 4 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 675666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briarcliff Health Center of Greenville 4400 Walnut St Greenville, TX 75401 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 0880 Provide and implement an infection prevention and control program. 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 establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 (Resident #1) resident reviewed for infection control. The facility failed to immediately implement Enhanced Barrier Precautions (EBP) for Resident #1 when she admitted on [DATE]. These deficient practices placed residents at risk for cross contamination and spread of infection.Findings included:Record review of Resident # 1's EMR and face sheet dated 10/08/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] and discharged on 09/05/2025. Her diagnoses included: Right femur (thigh bone) fracture, sacral region (area of the back and buttocks) pressure ulcer, right buttock pressure ulcer, left buttock deep tissue injury, MRSA (Methicillin Resistant Staphylococcus Aureus, a type of bacteria that is resistant to many antibiotics), right lung cancer with lobectomy (removal of lobe of lung), post-operative anemia (blood loss after surgery), and Osteoporosis (a bone disorder where bones become thinner). Record review of Resident #1's admission MDS assessment dated [DATE] reflected that she was admitted from a short-term general hospital. The MDS report indicated she admitted with surgical wounds after hip replacement, an unstageable pressure ulcer to her right buttocks, a Stage 2 pressure ulcer to her sacrum and a deep tissue injury to her left buttock. She scored 15/15 on her BIMS which signified she was cognitively intact. Record review revealed resident required supervision in eating, maximum assistance in toileting, moderate assistance in upper body dressing and was dependent in lower body dressing, bathing, bed mobility and transfers. Record review of Resident #1's EMR Medication Administration Record dated August 2025 reflected Enhanced Barrier Precautions (EBP) were implemented on 08/12/2025, six days after admission. Record review of Resident #1's Order Summary Report printed 10/07/2025 revealed active order for EBP with start date of 08/12/2025, six days after admission. An interview on 10/08/2025 at 10:51 a.m. with LVN A revealed she believed EBP should be implemented on all residents with wounds, catheters, feeding tubes and urinary or respiratory infections. LVN A stated she would notify the DON if a resident did not have the proper PPE and signs available that reflected EBP. LVN A stated she was not the nurse who admitted Resident #1 and does not recall if EBP was utilized by staff prior to 08/12/2025. An interview on 10/08/2025 at 10:58 a.m. with NA E revealed she would only know if someone required PPE to be worn if there was a sign posted on the door. NA E stated she knows to wear PPE with feeding tube and catheters. NA E stated if the resident had wounds, she would only know if the nurse told her at start of shift.An interview on 10/08/2025 at 11:00 a.m. with NA C revealed she would notify the charge nurse if PPE was not available for residents who needed it. NA C stated that residents with a catheter, feeding tube and infections need EBP when she works with them. NA C stated she knows which residents have EBP needs because they have a sign on their door.An interview on 10/08/2025 at 11:03 a.m. with NA D revealed that she would wear PPE for residents who have the EBP sign posted on their door. NA D stated that she would ask the charge nurse if she did not know what the EBP need was for a particular resident. NA D stated she would not know that a resident required EBP if there was not a sign on his/her door.An interview on 10/08/2025 at 2:00 p.m. with LVN B revealed that she believed EBP was implemented on all residents who required PPE be utilized to prevent infection, contain infection and prevent spread of infection. LVN B stated that residents who had wounds would require EBP use by all staff during interactions. An interview on 10/08/2025 at 3:30 p.m. with the DON revealed that she expects nursing staff to implement EBP for all residents who have open wounds to prevent spread of infection. The DON stated she expects the admitting nurse and/or wound Residents Affected - Few (continued on next page) FORM CMS-2567 (02/99) Previous Versions Obsolete Event ID: Facility ID: 675666 If continuation sheet Page 3 of 4 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 675666 B. Wing A. Building (X3) DATE SURVEY COMPLETED 11/21/2025 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Briarcliff Health Center of Greenville 4400 Walnut St Greenville, TX 75401 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 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few FORM CMS-2567 (02/99) Previous Versions Obsolete treatment nurse to identify EBP needs when the resident is admitted and to ensure appropriate signs are posted on the resident's door, PPE container is available at room entrance and orders obtained for EBP as needed. The DON stated she does not know why Resident #1 did not receive orders for EBP until six days after admission and acknowledged that she should have been under EBP since admission due to her wound care needs. The DON stated failures to ensure EBP were in place would place the resident at greater risk for increased infection and spread of infection due to poor infection control procedures.An interview on 10/08/2025 at 3:30 p.m. with the Administrator revealed that she expected nursing staff to follow all protocols and procedures for infection control for all residents. The Administrator stated that poor infection control could result in harm or injury to identified resident and other residents and increase the chance of spreading infection throughout the facility.Record review of policy and procedures for Infection Control titled, Infection Control Guidelines for All Nursing Procedures, Revised August 2021 revealed 2. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent the spread of infection. Event ID: Facility ID: 675666 If continuation sheet Page 4 of 4