Health inspection·December 13, 2023

F 0641 Ensure each resident receives an accurate assessment. 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 assessments accurately reflected the resident's status for 1 of 17 resident reviewed for assessments. (Resident #37) Residents Affected - Few The facility coded Resident #37's use of Aspirin (is used to treat pain and reduce fever or inflammation) as an anticoagulant (are medicines that help prevent blood clots) not an antiplatelet (are medications that prevent blood clots from forming. They work by stopping your platelets from sticking together) on his MDS. This failure could place residents at risk of not having individual needs met. Findings included: Record review of Resident #37's face sheet printed 12/11/23 indicated Resident #37 was a [AGE] year-old male and admitted on [DATE] with diagnoses including cerebral infarction (stroke) and hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles). Record review of Resident #37's consolidated physician order printed 12/13/23 indicated Aspirin (an antiplatelet) 81 mg tablet, delayed release, 1 tablet by mouth 1 time per day, start date 06/15/23. No end dates were included. Record review of Resident #37's quarterly MDS assessment dated [DATE] indicated Resident #37 was usually understood and usually had the ability to understand others. The MDS indicated Resident #37 had a BIMS score of 02 which indicated severely impaired cognition. The MDS indicated Resident #37 had taken an anticoagulant during the last 7 days of the assessment period. The MDS did not indicate Resident #37 had taken antiplatelet. Record review of Resident #37's care plan printed 12/12/23 did not indicated use of an anticoagulant or antiplatelet. During an interview on 12/13/23 at 1:59 p.m., the MDS coordinator said she was responsible for MDS coding. She said Aspirin should not be classified as an anticoagulant but an antiplatelet according to her manual. She said the wrong classification was a human error. She said in October (2023) the MDS process had a lot of changes so it may have contributed to the error. She said a corporate MDS coordinator did monitor and audit the MDSs, but she did not know how often. She said the corporate MDS coordinator was in the facility to help in October (2023), but she was solely responsible for the submitted MDSs. Page 1 of 27 676051 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0641 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/13/23 at 2:08 p.m., the DON said Aspirin was classified as an antiplatelet not an anticoagulant. She said the corporate MDS coordinator did audits but did not know how often. She said accuracy of assessment was important because it was important. During an interview on 12/13/23 at 3:02 p.m., the ADM said he expected the MDS coordinator to follow her policies and procedures regarding MDS coding of medications. Record review of a facility's Resident Assessment policy dated 01/12/20 indicated .to assess each resident's strengths, weakness, and care needs .to use this assessment data to develop a person-centered comprehensive plan of care for each resident that will assist a resident in achieving and maintaining the highest practical level .each individual who completes a portion of the assessment will sign to certify accuracy of that portion . 676051 Page 2 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0645 PASARR screening for Mental disorders or Intellectual Disabilities Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and interviews, the facility failed to ensure residents diagnosed as having a mental illness were screened and evaluated prior to admission by the local authority and receive care and services in the most integrated setting appropriate to their needs for 1 of 4 residents reviewed for PASRR screening. (Resident #26). Residents Affected - Few The facility failed to correctly screen on admission, and refer, Resident #26 who was diagnosed with mental illness to the appropriate state designated mental health or ID authority for evaluation. This failure placed 1 resident at risk and could affect other residents with psychiatric diagnoses for not being assessed by the local authority and not receiving services to prevent declines. Findings included: Record review of Resident #26's Face Sheet reflected a [AGE] year-old-male had an admission date of 10/11/2023 with diagnoses of osteomyelitis (an inflammation or swelling of bone tissue that is usually the result of an infection), post-traumatic stress disorder (PTSD-a real disorder that develops when a person has experienced or witnessed a scary, shocking, terrifying, or dangerous event), and anxiety (an emotion characterized by feelings of tension, worried thoughts, and physical changes like increased blood pressure). Record review of Resident #26's MDS assessment dated [DATE] reflected a BIMS score of 15 (reflecting Cognitively Intact) and section A 1500 Resident evaluated by PASRR (Preadmission Screening and Resident Review) was marked as No for mental illness section and section I was marked Yes for the mental illnesses of PTSD, depression, and anxiety. Review of Resident #26's Care Plan dated 12/11/2023 reflected Resident #26's had PTSD and tended to speak belittling to family and staff. The interventions were listed as decreasing stimulation and eliminating boredom. Review of the PASRR Level (1) one screening form for Resident #26 dated 10/13/2023 reflected he had evidence of mental illness . During an interview on 12/13/2023 at 2:15 p.m. the MDS nurse stated she was unaware PTSD was a form of mental illness that was required to be documented on the PL1 form submitted by the facility. The MDS nurse stated she was aware of diagnoses of schizophrenia, bipolar, manic depression, and major depressive disorder needing to be marked as mental illness on the PL1. The MDS nurse stated a 1013 form to correct a level one PASRR would be completed on Resident #26 to reflect his PTSD diagnosis. During an interview on 12/13/2023 at 2:30 p.m. the DON stated she was unaware of the miscoding of the PASRR Level 1. The DON stated it was the responsibility of the MDS nurse or the social worker to ensure the PASRR information is entered and correct. The DON stated not having a properly coded PASRR level one could keep the residents from getting needed services for their mental health. During an interview on 12/13/2023 at 2:35 p.m. the Administrator stated he expected staff to screen all residents for PASRR. The Administrator stated the facility used the guidance of the Center for Medicare and Medicaid by following the RAI (Resident Assessment Instrument) manual and did not have 676051 Page 3 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0645 a PASRR policy. Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few 676051 Page 4 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

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 observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 17 residents reviewed for care plans. (Resident #17) The facility failed to develop a care plan intervention of appropriate footwear for Resident #17, after her fall on 11/09/23. The facility failed to implement Resident #17's fall intervention to use of a walker after her fall on 11/09/23. These failures could place residents at risk of not having individual needs met and cause residents not to receive needed services. Findings included: Record review of Resident #17's face sheet printed 12/11/23 indicated Resident #17 was an [AGE] year-old female and admitted on [DATE] with diagnoses including senile degeneration of brain (is characterized by a decrease in cognitive abilities or mental decline) and dementia (a group of thinking and social symptoms that interferes with daily functioning). Record review of Resident #17's admission MDS assessment dated [DATE] indicated Resident #17 was usually understood and sometimes had the ability to understand others. The MDS indicated Resident #17 had a BIMS score of 03 which indicated severely impaired cognition. The MDS indicated Resident #17 wandered. The MDS indicated Resident #17 required supervision or touching assistance for walking at least 10 feet and 50 feet with two turns, and partial/moderate assistance for walking 150 feet. The MDS did not indicate what mobility devices were normally used in the last 7 days of the assessment period. The MDS indicated Resident #17 had occasional urinary incontinence and always had bowel continence. The MDS indicated Resident #17 did not have a fall history on admission. Record review of Resident #17's care plan dated 10/16/23 indicated Resident #17 was a fall risk related to fall (11/09/23) and fall risk score of 7-18= High risk as evidence by cognitive status: severely impaired, transfer: limited assist, and vision: wears glasses. Intervention included assess for potential fall-related injury prevention, looking at circumstances, location, medication, new or worsening medical problem, etc. and walker. Record review of Resident#17's fall risk assessment, completed on 11/09/23 by LVN E, indicated Resident #17 had intact cognitive status, 3 or more present general condition, independent/supervision mobility, required limited assistance for transfer, was full weight bearing, used a walker as assisted device, wears glasses, had occasional incontinence, and received two or more medication. Score: 7-18 high risk. Record review of Resident #17's incident/accident report, initiated by LVN E on 11/09/23, indicated .fall .witnessed by CNA B .bruise/discoloration .bruise to right pinky finger with small abrasion, abrasion to right elbow .location of incident: hallway .activity at time of incident: standing in the hall assisted .fall witnessed by CNA B states Resident #17 lost balance and fell in hallway; 676051 Page 5 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0656 states fall was seen; states fall was broken to avoid injury .redirect resident #17 as needed for safety . Level of Harm - Minimal harm or potential for actual harm During an observation on 12/11/23 at 10:39 a.m., Resident #17 was in the main area with house shoes with no backing covering her heels. Resident #17 was not using a walker. Residents Affected - Few During an observation on 12/11/23 at 11:19 a.m., Resident #17 was wandering the hallway with house shoes with no backing covering her heels. Resident #17 was not using a walker. On 12/11/23 at 2:20 p.m., attempted to contact a family member of Resident #17's. Unable to leave message. During an observation on 12/12/23 at 11:17 a.m., Resident #17 was walking around halls and opening resident's room doors. Resident #17 was wearing house shoes with no backing covering her heels and walker. During an observation on 12/12/23 at 3:15 p.m., Resident #17 was wandering the main dining area wearing house shoes with no backing covering her heels and walker. A rollator walker was noted in the corner of the room. CNA B offered Resident #17 the rollator walker. Resident #17 placed on her hand on the rollator walker as if she was going to use it, then declined and wandered off. During an interview on 12/12/23 at 3:10 p.m., CNA B said she had worked on the secured unit for 7 years. She said Resident #17 had one fall since admission in the hallway. She said the fall probably was due to her shoes with no heel support. She said all of Resident #17's shoes were with no heel support. She said the shoes with no backing was probably not safe because Resident #17 shuffled her feet when she walked. She said after the fall, the facility intervention was to encourage Resident #17 to use her walker but she rarely used it. During an interview on 12/13/23 at 1:15 p.m., LVN D said resident's current footwear was high fall risk and should probably have heel support. She said the facility could ask the family to bring more appropriate footwear for a resident. She said she did not know what Resident #17's interventions were after her fall. She said a resident's care plan interventions should be developed or implemented to prevent further incidents or accidents and help communicate with a resident. She said staff had access to a resident care plan. During an interview on 12/13/23 at 2:08 p.m., the DON said Resident #17's intervention after her fall was x-rays which did not show fractures. She said another intervention was redirect as needed. She said Resident #17's fall was witnessed in the hallway. She said the facility assessed resident's footwear for appropriateness. She said Resident #17 normally wore nonslip socks. She said after the fall, staff only said Resident #17 lost her balance not tripped. She said it depended on the day if Resident #17 wore house shoes was safe, but she had not fallen again since the first incident. Record review of a Fall Management policy reviewed on 01/12/20 indicated .the community will identify each resident who is at risk for falls and will plan care and implement interventions to manage falls .upon determination that the resident is at risk, the qualified staff creates an individualized plan of care that included the appropriate preventative interventions to reduce potential for falls . Record review of a Comprehensive Care Plans reviewed 04/17/23 indicated .it is the policy of the 676051 Page 6 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0656 Level of Harm - Minimal harm or potential for actual harm facility to develop and implementation a comprehensive person-centered care plan for each resident .the care planning process will include an assessment of the resident's strength and needs, and will incorporate the resident's personal and cultural preferences in developing goals of care .services provided or arranged by the facility, as outlined by the comprehensive care plan .the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being . Residents Affected - Few 676051 Page 7 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as possible and each resident receives adequate supervision to prevent avoidable accidents for 4 of 17 residents reviewed for accidents. (Residents #52, Resident #23, Resident #17, and Resident #54) The facility failed to ensure the ice machine was always locked to prevent Residents #52 and #23 from getting ice themselves. The facility failed to ensure Resident #17, and Resident #54 had adequate supervision after a resident-to-resident altercation. The facility failed to ensure Resident #54 did not have cleaning supplies in his room. These failures could place residents at risk of injury from accident and hazards. Findings included: 1. Record review of the face sheet dated 12/12/23 revealed Resident #52 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, heart disease, and high cholesterol. Record review of the quarterly MDS assessment dated [DATE] revealed Resident #52 was understood and usually understood others. The MDS revealed Resident #52 had a BIMS of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #52 was independent with ADLs. Record review of the care plan last revised on 12/10/23 revealed Resident #52 had impaired physical mobility. There was an intervention to provide an appropriate level of assistance to promote safety of the resident. Record review of a Skin Data form dated 12/06/23 indicated there was bruising to Resident #52's left arm. Record review of a Skin Data form dated 12/13/23 indicated there was bruising to Resident #52's left arm. There was a note that indicated, resident noted with bruising to left wrist with redness surrounding bruise 2. Record review of the face sheet dated 12/13/23 revealed Resident #23 was [AGE] years old and admitted on [DATE] with diagnoses including weakness, high blood pressure, and urinary tract infection. Record review of an MDS assessment dated [DATE] revealed Resident #23 was understood and understood others. The MDS revealed Resident #23 had a BIMS of 15 which indicated no cognitive impairment. The MDS indicated Resident #23 was independent with some ADLs and required limited assistance with some ADLs. Record review of the care plan last revised on 12/10/23 revealed Resident #23 had impaired physical 676051 Page 8 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some mobility with left sided weakness and right lower extremity weakness. There was an intervention to provide an appropriate level of assistance to promote safety of the resident. During an observation on 12/11/23 at 12:03 p.m., Resident # 52 propelled herself in her wheelchair to the ice machine in the dining room. The ice machine lid was closed, and the pad lock was hanging, unlocked. There were no staff members present. The resident opened the ice machine and filled a cup with ice using the scoop. When Resident #52 closed the lid it fell hitting her on her left arm/left wrist, narrowly missing her head and face. There was a sign on the lid of the ice machine that read, Employees Only. Keep lid closed and locked. During an observation and interview on 12/11/23 at 12:07 p.m., Resident #52 was in her room in a wheelchair. She said she had just gotten ice out of the ice machine. She had a fresh bruise to her left forearm, left wrist area. She said she did not know where she had gotten the bruise. She said she had just looked down and it was there. During an observation on 12/11/23 at 2:10 p.m., the pad lock on the ice machine in the dining room was hanging open and unlocked. There were residents present in the dining room and there was no staff present. During an observation on 12/12/23 at 8:00 a.m., the pad lock on the ice machine in the dining room was hanging open and unlocked. There were residents present in the dining room and there was no staff present. During an interview on 12/12/23 at 8:36 a.m., Resident #52 said staff would help her get ice but she liked to get it on her own so she could get out of her room. During an observation on 12/12/23 at 10:10 a.m., the pad lock on the ice machine in the dining room was hanging open and unlocked. There were residents present in the dining room and there was no staff present. During an interview on 12/12/23 at 4:14 p.m., Resident #23 said the staff rarely serve the residents ice. She said maybe once a month they brought ice to their rooms. She said when she wanted ice she had to get it herself. She said she had gone to the ice machine and gotten ice by herself without any staff assistance in the past. She said there were times the ice machine was locked but not always. During an interview on 12/13/23 at 9:56 a.m., the Dietary Manager said the key to the ice machine hung on the wall beside the ice machine. She said nursing staff were able to get ice out of the ice machine and dietary staff might not always be aware that it was unlocked. She said the lock was placed on the ice machine to begin with so residents could not get in the ice machine on their own. During an interview on 12/13/23 at 12:45 p.m., LVN D said only employees should have access to the ice machine. She said the ice machine was supposed to stay locked and only employees knew where the key was. She said the door of the ice machine was heavy and will fall on you if you are not careful. She said she had just completed a skin assessment on Resident #52, and she did have a new bruise her left arm, left wrist area. She said the resident denied getting ice out of the ice machine to her. The resident denied the bruise came from the ice machine door falling on her. During an interview on 12/13/23 at 12:57 p.m., the DON said she would have expected for the ice 676051 Page 9 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some machine to have been kept locked and residents to not have had access to the ice machine. She said staff do use the ice machine. She said, if you unlock it, you are supposed to lock it back. During an interview on 12/13/23 at 1:30 p.m., the Administrator said the ice machine needed to be kept locked. He said residents using the ice machine caused contamination. He said the ice machine should be kept always locked. 3. Record review of Resident #17's face sheet printed 12/11/23 indicated Resident #17 was an [AGE] year-old female and admitted on [DATE] with diagnoses including senile degeneration of brain (is characterized by a decrease in cognitive abilities or mental decline), dementia with other behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning) and anxiety (experience fear and worry that is both intense and excessive). Record review of Resident #17's admission MDS assessment dated [DATE] indicated Resident #17 was usually understood and sometimes had the ability to understand others. The MDS indicated Resident #17 had a BIMS score of 03 which indicated severely impaired cognition. The MDS indicated Resident #17 wandered which placed the resident at significant risk of getting to a potentially dangerous place. The MDS indicated Resident #17 had other behavioral symptoms not directed towards others (e.g., hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing, or smearing food or bodily wastes, or verbal/vocal symptoms like screaming, disruptive sounds) which occurred 1 to 3 days during the 7-day assessment period. The MDS indicated Resident #17 required partial/moderate assistance for oral and toilet hygiene, dressing, and putting on footwear, and substantial/maximal assistance for shower/bathe self. Record review of Resident #17's care plan dated 11/07/23 indicated Resident #17 had behavioral changes related to resident-to-resident altercation and moderate elopement risk. Interventions included 11/5/23 resident [Resident #17] redirected to room and assisted to bed, monitored closely while out of room, easily redirectable, no signs and symptoms of agitation noted, no further incidents and remove resident from immediate situation to assure safety. On 12/11/23 at 2:20 p.m., attempted to contact a family member of Resident #17's. Unable to leave message. 4. Record review of Resident #54's face sheet printed 12/11/23 indicated Resident #54 was a [AGE] year-old male and was admitted on [DATE] with diagnoses including dementia with other behavioral disturbance, amnesia (is memory loss or the inability to form new memories), and dysarthria (is a condition in which the part of your brain that controls your lips, tongue, vocal cords, and diaphragm doesn't work well) and anarthria (is a complete loss of speech). Record review of Resident #54's annual MDS assessment dated [DATE] indicated Resident #54 was sometimes understood, sometimes had the ability to understands others, and had unclear speech. The MDS indicated Resident #54 was rarely/never understood and a BIMS could not be conducted. The MDS indicated Resident #54 had short- and long-term memory recall problems and moderately impaired cognitive skills for daily decision making (decision poor; cues/supervision required). The MDS indicated Resident #54 had physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually). The MDS indicated Resident #54's current behavior status, care rejection, or wandering had worsened compared to prior assessment. The MDS indicated Resident #54 required supervision or touching assistance for walking, transfer, toilet hygiene and shower, partial/moderate assistance for dressing, and substantial/maximal assistance for personal hygiene. 676051 Page 10 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some Record review of Resident #54's care plan dated 11/07/23 indicated Resident #54 had behavioral changes related to environmental triggers, loss of independence, resident to resident altercation (11/05/23), and moderate elopement risk as evidence by family support system, behavioral aggression, verbally abusive, and resists care. Interventions included resident [Resident #54] redirected to room and assisted to bed, monitored closely while out of room, easily redirectable, no signs and symptoms of agitation noted, no further incidents, redirect, and remove resident from immediate situation to assure safety. Record review of the facility's provider investigation report dated 11/05/23 indicated . [Resident #17] and [Resident #54] in dining room had altercation .resident separated and assisted to rooms then bed after incident .both residents did not have any recall of incident .CNA assignment changed to ensure maximum observation . Record review of CNA C's witness statement dated 11/05/23 indicated .I, [CNA C] .[Resident #17] and [Resident #54] got into an incident in the dining room on memory care .I [CNA C] was off of memory care in another room .I [CNA C] came back to memory care .{Resident #17] and [Resident #54] was in the dining room .[Resident #17] was in his face [Resident #54], he grabbed her lower arm, she [Resident #17] hit him on the upper arm .he [Resident #54] had his arm raised to hit her back .I [CNA C] and a family member of a different resident, grab his [Resident #54] arm to stop him from hitting her back . During an observation on 12/11/23 at 10:39 a.m., Resident #17 was in another male's personal space, trying to get him to do something. Resident #17 was redirected from the male resident. During an observation on 12/11/23 at 11:15 a.m., CNA G was with another resident in a different area of the unit watching the Christmas tree get decorated. Resident #54 was in the main dining area with no supervision. During an observation on 12/11/23 at 11:15 a.m.-11:19 a.m., Resident #17 was wandering the hallway and entered other resident's rooms and main dining area, unsupervised. During an observation on 12/12/23 at: *11:12 a.m. CNA B took another resident into the shower room. Resident #54 was left in the main dining area with a female resident, unsupervised. *11:17 a.m. CNA B was still in shower room with a resident. One female was crying and walking the halls. The crying female resident went into another resident room. *11:21 a.m. CNA B was still in shower room with a resident. Resident #17 and the tearful female resident were wandering the hallways together, unsupervised. Resident #17 was observed opening resident's room doors. *11:23 a.m. CNA B was still in shower room with a resident. Resident #17 and a female resident entered a male resident's room. Male resident invited the female residents in the room. The female resident told Resident #17, No. That's a man's room. Resident #17 shut the door and they continued wandering the hallways together, unsupervised. *11:25 a.m. CNA B was still in shower room with a resident. A nurse arrived on the unit but went 676051 Page 11 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Minimal harm or potential for actual harm into another resident's room and shut the door to assist her to the bathroom. Resident #17 and Resident #54 were unsupervised. *11:30 a.m. CNA B was still in shower room with a resident. The AD arrived on the secured unit with an activity. Residents Affected - Some During an observation on 12/12/23 at 11:31 a.m., Resident #54's room door was open. On the bottom cabinet, of Resident #54's furniture, holding his refrigerator were 8 bottles of cleaning supplies and a box of mopping cloths. During an interview on 12/12/23 at 3:10 p.m., CNA B said residents on the secured unit were not allowed to have cleaning supplies. She said she had not noticed them in Resident #54's room. She said cleaning supplies not locked up was not safe on a dementia unit. She said the resident may not know the cleaning supplies were not safe. She said residents wandered into each other rooms. She said the resident could drink or spray the chemicals in their eye. She said if the resident drank the chemicals, it could be harmful and cause hospitalization or death. CNA B said Resident #17 and Resident #54 had an altercation last month. She said 3-4 months ago the memory care unit became co-ed. She said Resident #17 could be calm but if she disagreed with you she got upset. She said Resident #17 did not respect other residents' personal space. She said she could normally be redirected. She said she did not know what interventions were put in place for Resident #17 and Resident #54 after their altercation. She said the memory care unit only had 6 resident and was staffed with 1 CNA. She said the nurse had 2 halls. She said every once in a while residents were left unsupervised for extended periods before and after the incident. She said Resident #17 and Resident #54 being unsupervised for an extended period was probably not a good idea since they had an altercation. She said other residents wandered and into resident's room that were territorial. She said residents being unsupervised could result in altercations or falls. She said she had not been instructed to get help when she had to leave the resident for a long period. During an interview on 12/13/23 at 11:44 a.m., CNA C said she worked the 6pm-6am shift on the secured unit. She said the evening of the altercation with Resident #17 and resident #54 she had the secured unit and rooms outside the unit. She said one of the residents outside of the unit was a total care resident. She said that evening she tried to get the residents to bed before she left the unit. She said Resident #17 was wandering and trying to open resident's bedroom doors. She said she had to go answer the total care resident call light twice and was gone about 15 minutes. She said when she left the last time, she saw Resident #54 leave his room and slowly head towards the main dining area. She said when she came back on the secured unit, she heard no no! She said when she got to the main dining area, Resident #54 had Resident #17 by the arm. She said Resident #54 raised his hand to hit Resident #17 but her and a family member of another resident stopped him. She said Resident #54 had Resident #17's wrist tightly in his hands. She said then Resident #17 tried to hit Resident #54. She said she finally got Resident #54 to let go of Resident #17's arm. She said after the incident, she took Resident #17 with her to report the incident and left the other resident with the family member. She said it was not good to have residents outside of the secured unit because the resident could not be watched, and they were unpredictable. She said she thought this was the first time Resident #54 was physically aggressive. She said Resident #17 did not respect or understand boundaries. She said after the altercation, the facility's intervention was not to assign the total care resident to the memory care CNA which would lead to residents being unsupervised. She said but if the facility was short staffed, then she still had residents outside the secured unit. During an interview on 12/13/23 at 1:15 p.m., LVN D said she had only heard about the altercation 676051 Page 12 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Some between Resident #17 and Resident #54. She said CNAs on the secured unit, were supposed to tell a nurse or aide when they went on break so someone could cover the unit. She said she did not know if the CNAs had been instructed to do that when they gave residents showers. She said if the facility is short staffed, the memory care CNA would have the front part of the hall, not secured. She said the memory care residents needed more supervision because they could have aggressive moments. She said resident being unsupervised could be hurt. LVN D said she thought all cleaning supplies were supposed to be locked up. She said cleaning supplies not locked up risked residents drinking them or putting it in their eyes. She said the facility would have to call poison control and resident could need hospitalization. She said the facility's department heads did ambassador rounds every morning and went into resident's rooms. During an interview on 12/13/23 at 1:58 p.m., the housekeeping supervisor said the housekeeping staff did not report to her Resident #54 had cleaning supplies in his room. She said the cleaning supplies were not safe because the residents could burn themselves or drink the supplies. She said the residents could give it to other residents not understanding it was not safe. She said the chemicals could make the residents sick or need to go to the hospital. During an interview on 12/13/23 at 2:08 p.m., the DON said Resident #17 tried to get resident to go to bed. She said Resident #17 approached Resident #54. She said CNA C had stepped of the secured unit and walked upon the altercation. She said they have not had another altercation. She said the night shift CNA only had the memory care unit after the altercation. She said the CNA should call a nurse to come back to the secured unit if they need help. She said she felt it was okay for residents on the secured unit to be unsupervised for extended periods of time. She said the unit was not a 1 on 1 unit or needed increased supervision. During an interview on 12/13/23 at 3:02 p.m., the ADM said he had only been at the facility for 2 months. He said the residents on the secured unit should not be left unsupervised. He said resident on the memory care unit were confused with swinging moods and needed more attention. He said the memory unit being co-ed presented some issue and was difficult. He said he expected staff to call another staff member for help if they were going to be off the unit or showering residents. He said even after the altercation, if the facility was short staffed, the CNA was assigned the unsecured front area of the hall. The ADM said the facility did not allow cleaning supplies to be stored in resident's rooms. He said he did not know how a CNA or housekeeper did not notice the cleaning supplies in Resident #54's room. He said if the chemical were ingested, it would not be good. He said the potential for other residents to get into the supplies was high because the residents wandered. He said not having cleaning supplies in the resident's room should be in the admission packet, but he was not sure. He said the facility's department heads did ambassador rounds every morning and went into resident's rooms. He said he was assigned the memory care unit and did not recall cleaning supplies in Resident #54's room. He said the cleaning supplies had to be brought over the weekend. Review of an undated Statement of Resident Rights facility policy indicated, .You have the right to .safe, decent and clean conditions . 676051 Page 13 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0692 Provide enough food/fluids to maintain a resident's health. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 4 resident (Resident #30) reviewed for hydration. Residents Affected - Few The facility failed to ensure Resident #30 received adequate hydration. These failures could place residents at risk for dehydration, electrolyte imbalance, and infections. Findings included: 1. Record review of a face sheet dated 12/11/2023 indicated Resident #30 was an [AGE] year-old male and originally admitted on [DATE] with a readmission noted on 12/09/2023 with diagnoses including hypoglycemia (a condition in which your blood sugar (glucose) level is lower than the standard range), metabolic encephalopathy ( comprise a series of neurological disorders not caused by primary structural abnormalities; rather, they result from systemic illness, such as diabetes, liver disease, renal failure and heart failure), and acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood). Record review of an MDS assessment dated [DATE] indicated Resident #30 required supervision of a helper to provide touch/steadying as the resident completed the activity for eating. The MDS indicated Resident #30 had impaired vision. The MDS indicated Resident #30 had a BIMS score of 03, which indicated severely impaired cognition. The MDS indicated Resident #30 was always incontinent for urinary and bowel. Record review of a care plan dated 12/09/2023 indicated Resident #30 was taking an antibiotic for a bacterial infection and the intervention was to encourage fluids. Record review of MD orders dated December 2023 listed Resident #30's diet as puree NAS diet with thin liquids. No fluid restriction was noted on MD orders. Resident #30 had an order for doxycycline hyclate 100mg twice daily x 5 days for urinary tract infection. Record review of nurse's notes dated 12/09/2023 at 5:24 p.m. written by the DON reflected Resident #30 was returning to the facility with no fluid restriction. Record review of Resident #30's EHR showed no recent (last 60 days) lab work on file. During an observation/interview on 12/11/2023 at 9:20 am a small cup of water (6 oz) was on the bedside table with approximately 3 oz of fluid in it. No water pitcher was noted in the room. The bedside table containing the small cup of water was out of reach of resident. Resident #30 was in a bed lowered to the floor with a fall mat about 2 feet wide next to the bed. The bedside table was on the other side of the fall mat raised to the highest position approximately 3.5 feet from the floor. Resident #30 requested a drink of water when surveyor entered room. Resident #30 had dry lips that were sticking to his teeth when he spoke. During an observation/interview on 12/11/2023 at 2:00 p.m. the small cup of water on bedside table 676051 Page 14 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0692 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few with approximately 3 oz of fluid in it continued to be out of reach by of the resident. Resident #30's bed remained in lowest position, fall mat beside bed and bedside table on other side of fall mat in highest position. Resident #30 stated I am so thirsty, why can't I have a drink? During an interview and observation on 12/12/2023 at 8:30 a.m., RN A stated Resident #30 was on a fluid restriction and could have no more than 50 cc (approximately 1.5 oz) of water with medications and he could not have a water pitcher in his room. Resident #30 stated he is thirsty and would like water and RN A informed the resident he could not have any water because he was on a fluid restriction. During an interview on 12/13/2023 at 11:30 a.m., the DON stated Resident #30 was not on a fluid restriction and it clearly stated that in the nurse's notes. The DON stated Resident #30 was encouraged fluids related to his urinary tract infection and acute kidney injury. The DON stated it was the responsibility of all nurses and CNAs to ensure the residents had fluids at the bedside and they were offered multiple times per day. During an interview on 12/13/2023 at 1:00 p.m., the Administrator stated he trusted the DON's clinical judgement because he was not a nurse and expected her to direct the nurses to follow orders given by the hospital doctors, as well as the facility physicians. Review of a Hydration policy dated 08/01/2018 reflected it was noted Residents at risk for dehydration will be identified, assessed, and provided with sufficient fluid intake to encourage adequate hydration All residents will have a water pitcher at bedside (excluding residents with fluid restrictions, thickened liquids or NPO diet order). 676051 Page 15 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0755 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 24 residents reviewed for pharmacy services. (Resident #30) The facility failed to obtain medication from the pharmacy ordered after a hospitalization for Resident #30. This failure could place residents at risk for inaccurate drug administration and cause Resident #30 weight loss and possible rehospitalization. Findings included: 1. Record review of a face sheet dated 12/11/2023 indicated Resident #30 was an [AGE] year-old male and originally admitted on [DATE] with a readmission noted on 12/09/2023 with diagnoses including hypoglycemia (a condition in which your blood sugar (glucose) level is lower than the standard range), metabolic encephalopathy ( comprise a series of neurological disorders not caused by primary structural abnormalities; rather, they result from systemic illness, such as diabetes, liver disease, renal failure and heart failure), and acute kidney failure (occurs when your kidneys suddenly become unable to filter waste products from your blood). Record review of a MDS assessment dated [DATE] indicated Resident #30 required supervision of a helper to provide touch/steadying as the resident completed the activity for eating. The MDS indicated Resident #30 had impaired vision. The MDS indicated Resident #30 had a BIMS score of 03, which indicated severely impaired cognition. The MDS indicated Resident #30 was always incontinent for urinary and bowel. Record review of a care plan dated 12/09/2023 indicated Resident #30 was taking dronabinol for appetite stimulation related to poor intake. Record review of hospital history and physical dated 12/09/2023 indicated Resident #30 was hospitalized related to hypoglycemia and acute kidney injury (kidneys suddenly stop working properly). Record review of MD orders dated December 2023 listed Resident #30's diet as puree NAS diet with thin liquids. Orders included Dronabinol 2.5 mg twice daily for decreased appetite beginning on 12/09/2023. Record review of the MAR dated December 2023 showed missed doses of dronabinol 2.5mg on 12/9/2023, 12/10/2023, and 12/11/2023. The indication on the MAR for not administering the medication was listed as medication not available. Record review of the nurses' notes dated 12/09/2023, 12/10/2023, and 12/11/2023 indicated no attempts to notify the MD or contact the pharmacy about the missing medication. During an interview on 12/12/2023 at 8:30 a.m., RN A stated she was unsure where the dronabinol was. She stated she would have to contact the pharmacy and see if it had been delivered or what the 676051 Page 16 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0755 Level of Harm - Minimal harm or potential for actual harm holdup was. RN A stated she would normally call the MD if a medication was not available and ask if it was ok to discontinue the order or write an order to administer the medication when the medication was available from the pharmacy. RN A stated this was the first day she worked with Resident #30 in which he had the missing medication. RN A stated there was no adverse effect to Resident #30 for missing the medication because he had improved appetite. Residents Affected - Few During an interview on 12/13/2023 at 11:30 a.m., the DON stated the medication came in mid-morning on 12/12/2023 and was initial dosed at that time. The DON stated she called the MD and got an order to carry the medication out for 10 days with the start date being 12/12/2023. The DON stated not having the dronabinol was a pharmacy delivery issue related to the medication requiring a triplicate. The DON stated the resident readmitted on Saturday and the pharmacy did not notify the physician of the need of a triplicate until Monday 12/11/2023. The dronabinol was not something the facility kept in their emergency kit for the nurses to have access to when not available from the pharmacy. The DON stated it was the charge nurses' job to ensure all residents received all ordered medication and to notify the MD and the DON if any medication were not in the facility to administer. During an interview on 12/13/2023 at 2:30 p.m., the Administrator said he expected the nurses to communicate with the DON and himself any problems they have getting anything they need for the residents from clothing to medications and equipment. The Administrator said the facility would have sent the van driver or marketer to the doctor's office to pick up a triplicate to get Resident #30 his medications. Review of a facility policy dated December 2012, titled Administering Medications stated, Medications must be administered in accordance with the orders, including any required time frame. Medications must be administered within one (1) hour of their prescribed time, unless otherwise specified. 676051 Page 17 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents who had not used psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record and PRN orders for psychotropic drugs were limited to 14 days for 2 of 5 residents (Resident #17 and Resident #44) reviewed for unnecessary psychotropic medications. The facility failed to provide an appropriate diagnosis for Resident #17's use of Mirtazapine (is used to treat depression). The facility failed to have an appropriate diagnosis for Resident #44's use of Risperidone (is a type of antipsychotic medication that treats mental health conditions schizophrenia, bipolar disorder, and some symptoms of autism). The facility failed to limit Resident #44's prn Hydroxyzine (is used as a sedative to treat anxiety and tension and to treat allergic skin reactions) for 14 days. These failures could put residents at risk of receiving unnecessary psychotropic medications. Findings included: 1. Record review of Resident #17's face sheet printed 12/11/23 indicated Resident #17 was an [AGE] year-old female and admitted on [DATE] with diagnoses including senile degeneration of brain (is characterized by a decrease in cognitive abilities or mental decline), dementia with other behavioral disturbance (a group of thinking and social symptoms that interferes with daily functioning) and anxiety (experience fear and worry that is both intense and excessive). Record review of Resident #17's admission MDS assessment dated [DATE] indicated Resident #17 was usually understood and sometimes had the ability to understand others. The MDS indicated Resident #17 had a BIMS score of 03 which indicated severely impaired cognition. The MDS indicated Resident #17 required partial/moderate assistance for oral and toilet hygiene, dressing, and putting on footwear, and substantial/maximal assistance for shower/bathe self. The MDS indicated Resident #17 had psychiatric/mood disorder of anxiety disorder not depression. The MDS indicated Resident #17 used an antidepressant during the last 7 days, but an indication was not noted. Record review of Resident #17's care plan dated 10/16/23 indicated Resident #17 used an antidepressant as evidence by Mirtazapine 30 mg tablet, 1 tablet by mouth 2 times per day. Interventions included monitor closely for worsening of depression and/or suicidal behavioral or thinking, monitor dosage, duration, interaction/adverse side effects, risk for falls, and administer medication as ordered. Record review of Resident #17's consolidated physician order printed 12/13/23 indicated Mirtazapine 30 mg tablet, 1 tablet by mouth 2 times per day, start date 10/16/23. Record review of Resident #17's eMar dated 12/01/23-12/13/23 indicated Mirtazapine 30 mg tablet, 1 676051 Page 18 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0758 tablet by mouth 2 times per day, DX: Senile degeneration of brain, start date: 10/16/23. Level of Harm - Minimal harm or potential for actual harm 2. Record review of Resident #44's face sheet printed on 12/11/23 indicated Resident #44 was a [AGE] year-old female and admitted on [DATE] and 07/24/22 with diagnosis including quadriplegia (is a symptom of paralysis that affects all a person's limbs and body from the neck down), hallucinations, depression (is a mood disorder that causes a persistent feeling of sadness and loss of interest), and anxiety disorder (is characterized by symptoms of intense anxiety or panic). Residents Affected - Few Record review of Resident #44's quarterly MDS assessment dated [DATE] indicated Resident #44 was understood and understood others. The MDS indicated Resident #44 had a BIMS score of 15 which indicated intact cognition. The MDS did not indicate Resident #44 experienced hallucination (perceptual experience in the absence of real external sensory stimuli) or delusion (misconception or belief that are firmly held, contrary to reality) during the assessment period. The MDS indicated Resident #44 was dependent for ADLs. The MDS did not indicate Resident #44 had diagnoses including schizophrenia (is a serious mental illness that affects how a person thinks, feels, and behaves), bipolar disorder (is a mood disorder that can cause intense mood swings), or psychotic disorder (are a group of serious illnesses that affect the mind). The MDS indicated Resident #44 received an antipsychotic and antianxiety during the assessment period. Record review of Resident #44's care plan dated 03/16/23 indicated Resident #44 had psychotropic drug use as evidence by Risperidone 0.5 mg tablet, 1 tablet by mouth at bedtime. Interventions included administer medication as ordered and monitor behavior every shift and document. Record review of Resident #44's consolidated physician orders printed 12/13/23 indicated Risperidone 0.5 mg tablet, 1 tablet by mouth at bedtime, start date 06/29/22. Record review of Resident #44's consolidated physician orders printed 12/13/23 indicated Hydroxyzine HCL 25 mg, 1 tablet by mouth every 8 hours as needed anxiety, start date 06/23/23. Record review of Resident #44's eMAR dated 12/01/23-12/13/23 indicated Risperidone 0.5 mg tablet, 1 tablet by mouth at bedtime, DX: Hallucinations, modification date: 07/28/22. Record review of Resident #44's eMAR dated 12/01/23-12/13/23 indicated Hydroxyzine HCL 25 mg, 1 tablet by mouth every 8 hours as needed anxiety, DX: Anxiety disorder, start date 06/26/23. No stop date was indicated. Record review of Resident #44's medication regimen review dated 10/03/23 indicated .prn psychotropic orders need a 14 day stop date .at that time physician will need to re-evaluate need for the following . Hydroxyzine HCL 25 mg PO every 6 hours PRN .duration greater than 14 days will need physician rationale .disagree .patient refuses change .MD H . During an interview on 12/13/23 at 1:15 p.m., LVN D said hallucination was not an approved diagnoses for Risperidone. She said she had never observed Resident #44 hallucinate but heard she did. She said she tried to make sure medication had appropriate diagnoses by confirming with the doctor when she took an order. She said an appropriate diagnosis was important, so you knew why you were giving the medication. She said she did not know if nurse management did chart audits to make sure medication had appropriate diagnosis. She said prn psychotropic drugs needed to be ordered for 14 days then reevaluate for continued use by the doctor. She said Mirtazapine was used as an appetite stimulant but was classified as an antidepressant. She said senile degeneration was not an appropriate diagnosis 676051 Page 19 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0758 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few for use of Mirtazapine. She said it was important to know why the right medication was ordered to treat the right condition. She said the diagnosis needed to match. During an interview on 12/13/23 at 2:08 p.m., the DON said Resident #44's Risperidone was ordered for hallucination. She said hallucination was an indication of use not a diagnosis. She said hallucination was not an approved diagnosis by CMS for Risperidone. She said Resident #44 being on Risperidone for hallucination affected the quality measure, but it was for the benefit of Resident #44. She said senile degeneration of the brain was an appropriate diagnosis for Mirtazapine. She said psychotropic prn medication needed to be ordered for 14 days. She said the physician should give a rationale for an order to extend past the time frame. She said she felt like the response on Resident #44's medication regimen review form patient refuses change addressed the pharmacy recommendation to add a 14-day end date even though there was no request to change the frequency or dosage. Record review of a facility Psychotropic Drugs-Use policy revised 07/27/22 indicated .the community will use psychotropic drug therapy when appropriate to enhance quality of life .antipsychotic: only appropriate for the following acceptable diagnosis (es): schizophrenia, Huntington's disease, Tourette's syndrome .careful evaluation of the residents' records should be reviewed for appropriate diagnosis for medication use .prn orders for psychotropic medication which are not antipsychotic medication are limited to 14 days .the attending physician/prescriber may extend the order beyond 14 days if he believes it is appropriate .if the attending physician extends the prn for the psychotropic medication .the medical record must contain a documented rationale and determined duration . 676051 Page 20 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0759 Ensure medication error rates are not 5 percent or greater. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 21.43%, based on 6 errors out of 28 opportunities, which involved 1 of 7 residents (Resident #30) reviewed for medication administration. Residents Affected - Some 1. RN A administered Brimonidine 0.2% eye drop (is used alone or together with other medicines to lower pressure inside the eye that is caused by open-angle glaucoma or ocular (eye) hypertension) in the right eye instead of the left eye as ordered on 12/12/23 for Resident #30. 2. RN A administered Moxifloxacin HCL eye drop (is an antibiotic that is used to treat bacterial infections of the eye) in the right eye instead of the left eye as ordered on 12/12/23 for Resident #30. 3. RN A administered Netarsudil (Rhopressa) 0.02% eye drop (is a prescription medication for the treatment of high eye pressure/intraocular pressure (IOP) in people with open-angle glaucoma or ocular hypertension) in the right eye instead of the left eye as ordered on 12/12/23 for Resident #30. 4. RN A administered Prednisolone AC 1% eye drop (treats eye swelling, redness, or itching caused by infections, injury, or other conditions) in the right eye instead of the left eye as ordered on 12/12/23 for Resident #30. 5. RN A administered 1 tablet of Vitamin C 500 mg (is a powerful antioxidant that may help the body form and maintain connective tissue, including bones, blood vessels) instead of 2 tablets as ordered for Resident #30. 6. RN A administered 1 soft gel of Vitamin E 200 IU 90 mg (is an essential nutrient and is the body's primary, fat-soluble antioxidant) instead of 2 soft gels for Resident #30. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders. Findings included: Record review of Resident #30's face sheet printed 12/13/23 indicated Resident #30 was an [AGE] year-old male and admitted on [DATE] and readmitted on [DATE] with diagnoses including myopia (is a common vision condition in which near objects appear clear, but objects farther away look blurry), bilateral, astigmatism (is an imperfection in the curvature of your eye's cornea or lens), bilateral, primary open-angle glaucoma (is a syndrome of optic nerve damage associated with an open anterior chamber angle), bilateral, and hyphema (is the collection of blood in the anterior chamber of the eye), left eye. Resident #30 was admitted to the facility less than 21 days ago. No MDS for Resident #30 was completed prior to exit. Record review of Resident #30's care plan dated 12/09/23 indicated antibiotic evidence by Moxifloxacin 0.5% eye drop 1 drop instill in left eye 3 times per day. Intervention included administer 676051 Page 21 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0759 medication as ordered. Level of Harm - Minimal harm or potential for actual harm Record review of Resident #30's care plan dated 12/12/23 indicated visual impairment related to pseudophakia of both eyes, hyphema, myopia of both eyes with astigmatism and presbyopia, and glaucoma as evidence by Brimonidine 0.2% eye drops, Latanoprost 0.005% eye drops (is used to treat certain kinds of glaucoma), Netarsudil (Rhopressa) 0.02% eye drops, and Prednisolone sodium phosphate 1% eye drops. Intervention included administer medications, treatments, and eye drops as ordered. Residents Affected - Some Record review of Resident #30's consolidated physician order printed 12/13/23 indicated Brimonidine 0.2% eye drops, 1 drop instill in left eye 3 times per day. Record review of Resident #30's consolidated physician order printed 12/13/23 indicated Moxifloxacin 0.5% eye drop 1 drop instill in left eye 3 times per day. Record review of Resident #30's consolidated physician order printed 12/13/23 indicated Netarsudil 0.02% eye drops, 1 drop instill in left eye every morning. Record review of Resident #30's consolidated physician order printed 12/13/23 indicated Prednisolone sodium phosphate 1% eye drops, 1 drop instill in left eye 3 times per day. Record review of Resident #30's consolidated physician order printed 12/13/23 indicated Vitamin C 500mg, 2 tablets by mouth every morning. Record review of Resident #30's consolidated physician order printed 12/13/23 indicated Vitamin E acetate 134 (200 unit) capsule, 2 capsule by mouth 1 time per day, may give 2 tablets = 400 units. Record review of Resident #30's eMAR dated 12/01/23-12/12/23 indicated Brimonidine 0.2% eye drops, 1 drop instill in left eye 3 times per day, DX; primary open-angle glaucoma, bilateral, start date 12/09/23. Record review of Resident #30's eMAR dated 12/01/23-12/12/23 indicated Moxifloxacin 0.5% eye drop 1 drop instill in left eye 3 times per day, DX: encounter for prophylactic measures, start date 12/09/23. Record review of Resident #30's eMAR dated 12/01/23-12/12/23 indicated Netarsudil 0.02% eye drops, 1 drop instill in left eye every morning, DX; primary open-angle glaucoma, bilateral, start date 12/09/23. Record review of Resident #30's eMAR dated 12/01/23-12/12/23 indicated Prednisolone sodium phosphate 1% eye drops, 1 drop instill in left eye 3 times per day, DX: Hyphema, left eye, start date: 12/09/23. Record review of Resident #30's eMAR dated 12/01/23-12/12/23 indicated Vitamin C 500mg, 2 tablets by mouth every morning, DX: encounter for prophylactic measures, start date: 12/09/23. Record review of Resident #30's eMAR dated 12/01/23-12/12/23 indicated Vitamin E acetate 134 (200 unit) capsule, 2 capsule by mouth 1 time per day, may give 2 tablets = 400 units, DX: encounter for prophylactic measures, start date: 12/09/23. 676051 Page 22 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0759 Level of Harm - Minimal harm or potential for actual harm Record review of RN A's competency evaluation for medication administration dated 11/29/23 indicated met for utilize the rights of medication to verify: resident, medication, dose, route, time, documentation and verifies medication order to order on card/bottle, medication is administered according to order, place the correct dosage in medication cup, instills ordered number of drops inside lower lid close to outside corner of eye. Residents Affected - Some During an observation 12/12/23 at 8:23 a.m., RN A placed 1 tablet of Vitamin C 500mg in a medicine cup then placed in clear baggy and crushed the tablet. RN A punctured 1 soft gel the squeezed out the medication then added it to the crushed medication. During an observation on 12/12/23 at 8:25 a.m., RN A gently pulled Resident #30's right eye and administered one drop of Brimonidine 0.2% eye drops. During an observation on 12/12/23 at 8:27 a.m., RN A gently pulled Resident #30's right eye and administered one drop of Moxifloxacin 0.5% eye drops. During an observation on 12/12/23 at 8:30 a.m., RN A gently pulled Resident #30's right eye and administered one drop of Netarsudil 0.02% eye drops. During an observation and interview on 12/12/23 at 8:33 a.m., RN A gently pulled Resident #30's right eye and administered one drop of Prednisolone sodium phosphate 1% eye drops. Surveyor asked RN A which eye the eye drops were supposed to go in and she said the left. RN A said, And I gave all those drops in the right eye! During an interview on 12/12/23 at 2:15 p.m., RN A said she had several years of experience and was previously a DON of a facility. She said she worked at the facility prn and this was her fifth time. She said she got nervous and got the left and right eye confused. She said her normal process for medication administration was verify the resident, medication, dose, route, and time before administration. She said she should have looked at the order and medication then oriented herself to the resident, so she did not administer the medication on her left side not his because she was facing him. She said not administering medications correctly could cause the affected area or problem to not be treated. During an interview on 12/13/23 at 2:08 p.m., the DON said she expected the nursing staff to follow the policy and procedures of medication administration. She said Resident #30 receiving 4 eye drops in the wrong eye did not negatively affect him. She said the doctor was notified and he was not concerned about adverse reaction of the eye drops. She said she did not how Resident #30 not receiving his full dose of Vitamin C and E affected him. During an interview on 12/13/23 at 3:02 p.m., the ADM said he expected the nursing staff to follow physician orders and medication administration policy and procedure. Record review of a facility's Medication-Guidelines of Clinical Practice policy revised 01/12/20 indicated .staff will provide medications in accordance with standard practice guidelines . 676051 Page 23 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

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 observation, interview, and record review, the facility failed to 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 2 of 17 residents reviewed for infection control. (Resident #52, Resident #23) Residents Affected - Few The facility failed to lock the ice machine when not in use by staff, leaving it accessible to residents. This failure placed residents at risk for cross contamination and infection. Findings include: 1. Record review of the face sheet dated 12/12/23 revealed Resident #52 was [AGE] years old and admitted on [DATE] with diagnoses including heart failure, heart disease, and high cholesterol. Record review of the quarterly MDS dated [DATE] revealed Resident #52 was understood and usually understood others. The MDS revealed Resident #52 had a BIMS of 10 which indicated moderate cognitive impairment. The MDS indicated Resident #52 was independent with ADLs. Record review of the care plan last revised on 12/10/23 revealed Resident #52 had impaired physical mobility. There was an intervention to provide an appropriate level of assistance to promote safety of the resident. 2. Record review of the face sheet dated 12/13/23 revealed Resident #23 was [AGE] years old and admitted on [DATE] with diagnoses including weakness, high blood pressure, and urinary tract infection. Record review of a MDS dated [DATE] revealed Resident #23 was understood and understood others. The MDS revealed Resident #23 had a BIMS of 15 which indicated no cognitive impairment. The MDS indicated Resident #23 was independent with some ADLs and required limited assistance with some ADLs. Record review of the care plan last revised on 12/10/23 revealed Resident #23 had impaired physical mobility with left sided weakness and right lower extremity weakness. There was an intervention to provide an appropriate level of assistance to promote safety of the resident. During an observation on 12/11/23 at 12:03 p.m., Resident # 52 propelled herself in her wheelchair to the ice machine in the dining room with a cup in her hand. The ice machine lid was closed, and the pad lock was hanging, unlocked. There were no staff members present. The resident opened the ice machine and filled a cup with ice using the scoop. During an observation and interview on 12/11/23 at 12:07 p.m., Resident #52 was in her room in a wheelchair. She said she had just gotten ice out of the ice machine. During an observation on 12/11/23 at 2:10 p.m., the pad lock on the ice machine in the dining room was hanging open and unlocked. There were residents present in the dining room and there was no staff present. 676051 Page 24 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0880 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an observation on 12/12/23 at 8:00 a.m., the pad lock on the ice machine in the dining room was hanging open and unlocked. There were residents present in the dining room and there was no staff present. During an interview on 12/12/23 at 8:36 a.m., Resident #52 said staff would help her get ice but she liked to get it on her own so she could get out of her room. During an observation on 12/12/23 at 10:10 a.m., the pad lock on the ice machine in the dining room was hanging open and unlocked. There were residents present in the dining room and there was no staff present. During an interview on 12/12/23 at 4:14 p.m., Resident #23 said the staff rarely serve the residents ice. She said maybe once a month staff bring ice to their rooms. She said when she wanted ice she had to get it herself in the past. She said she had gone to the ice machine and gotten ice by herself without any staff assistance. She said there were times the ice machine was locked but not always. During an interview on 12/13/23 at 9:56 a.m., the Dietary Manager said the key to the ice machine hung on the wall beside the ice machine. She said any staff that got ice out of the ice machine should lock it when they were finished. She said nursing staff were able to get ice out of the ice machine and dietary staff might not always be aware that it was unlocked. She said the lock was placed on the ice machine to begin with so residents could not get in the ice machine on their own. She said residents using the ice machine could cause cross contamination. During an interview on 12/13/23 at 12:45 p.m., LVN D said only employees should have access to the ice machine. She said the ice machine was supposed to stay locked and only employees knew where the key was. During an interview on 12/13/23 at 12:57 p.m., the DON said she would have expected for the ice machine to have been kept locked and residents to not have had access to the ice machine. She said staff do use the ice machine. She said, if you unlock it, you are supposed to lock it back. She said residents getting their own ice out of the ice machine could lead to the ice being contaminated. During an interview on 12/13/23 at 1:30 p.m., the Administrator said the ice machine needed to be kept locked. He said residents using the ice machine caused contamination. He said the ice machine should be kept always locked. Review of an undated Statement of Resident Rights facility policy indicated, .You have the right to .safe, decent and clean conditions . Review of an Infection Prevention and Control Surveillance facility policy dated July 2018 indicated, .A major function of the Infection Prevention and Control Program is to promote infection prevention and control strategies . 676051 Page 25 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0908 Keep all essential equipment working safely. 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 ensure all patient care equipment was in safe operating condition for 1 of 2 resident (Resident#37) reviewed for safe, functional equipment. Residents Affected - Few The facility failed to ensure Resident #37's wheelchair left armrest had padding. This failure could place residents at risk for skin issues and discomfort. Findings included: Record review of Resident #37's face sheet printed 12/11/23 indicated Resident #37 was a [AGE] year-old male and admitted on [DATE] with diagnoses including cerebral infarction (stroke), hemiplegia (muscle weakness or partial paralysis on one side of the body that can affect the arms, legs, and facial muscles), and aphasia (a language disorder that affects a person's ability to communicate). Record review of Resident #37's quarterly MDS assessment dated [DATE] indicated Resident #37's preferred language was Spanish. The MDS indicated Resident #37 was usually understood and usually had the ability to understand others and had unclear speech. The MDS indicated Resident #37 had a BIMS score of 02 which indicated severely impaired cognition. The MDS indicated Resident #37 required partial/moderate assistance for personal hygiene and was independent for eating, oral hygiene, toileting hygiene, and transfer. The MDS indicated Resident #37 used a wheelchair as a mobility device. The MDS indicated Resident #37 had impairment on one side on his upper and lower extremities. Record review of Resident #37's care plan dated 06/15/23 indicated Resident #37 was at risk/actual skin breakdown related to history of stroke and cardiovascular disease as evidence by mild score for risk of pressure ulcer, right sided weakness, and confined to chair most of the time. Intervention included position resident properly, use pressure reducing or pressure relieving devices if indicated. During an observation on 12/11/23 at 10:59 a.m., Resident #37 was sitting in the dining room in his wheelchair. Resident #37 propelled himself with his left arm and his right arm was flaccid (is not firm or stiff). Resident #37's left armrest cushion was 75% missing on his wheelchair. During an observation on 12/11/23 at 11:12 a.m., Resident #37's was in his wheelchair headed down the hallway towards the main dining area. Resident #37 propelled himself with his left arm and his right arm was flaccid. Resident #37's left armrest cushion was 75% missing on his wheelchair. Resident #37 had unclear speech and difficulty communicating. During an interview on 12/12/23 at 3:10 p.m., CNA B said she had not noticed Resident #37 was missing part of his armrest cushion. She said therapy repaired resident's wheelchairs. She said Resident #37 not having an armrest cushion on his wheelchair could cause him to scratch or hurt himself. During an interview on 12/13/23 at 11:44 a.m., CNA C said she had not noticed Resident #37 was missing part of his armrest cushion. She said wheelchair repairs were placed in the maintenance book and a nurse was informed of the issue with the wheelchair. She said the missing armrest cushion could cause Resident #37 skin tears. 676051 Page 26 of 27 676051 12/13/2023 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0908 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few During an interview on 12/13/23 at 12:56 p.m., COTA J said the therapy department was not responsible for wheelchair maintenance. She said if she noticed an issue, she would make sure it got fixed. During an interview on 12/13/23 at 1:15 p.m., LVN D said she had not noticed Resident #37 was missing part of his armrest cushion. She said the missing armrest cushion could cause skin problems and falls. She said maintenance fixed resident's wheelchair, but staff had to place the repairs on the maintenance log. She said the maintenance supervisor was supposed to check the logbook every morning for repairs. During an interview on 12/13/23 at 1:54 p.m., the maintenance supervisor said staff were supposed to place repairs in the maintenance logbook which was at the nurse's station. He said he checked the logbook every morning and before he left for the day. He said he was responsible for wheelchair maintenance. He said he did not know about Resident #37's wheelchair until yesterday when he fixed it. He said he did not do routine wheelchair audits to check resident's wheelchairs. During an interview on 12/13/23 at 2:08 p.m., the DON said maintenance was responsible for wheelchair repairs. She said repairs should be placed on the maintenance log by staff members. She said it did not affect Resident #37 to not have padding on his wheelchair armrest. She said not having padding on Resident #37's wheelchair armrest did not pose a risk. During an interview on 12/13/23 at 3:02 p.m., the ADM said maintenance was responsible for wheelchair repairs and therapy if they received services. He said repairs should be placed on the maintenance log by staff members. He said no wheelchair cushion placed resident at risk for skin tears and needed to be addressed as soon as possible. Record review of an undated facility's Maintenance Service policy indicated .maintenance service shall provide to all areas of the buildings, grounds, and equipment .equipment in a safe and operable manner at all times . 676051 Page 27 of 27