Health inspection·November 5, 2025

F 0689 Level of Harm - Immediate jeopardy to resident health or safety 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 residents remained free from accidents, hazards, and each resident received adequate supervision and assistance while providing care for 3 of 8 residents (Resident #1, Resident #2, and Resident #3) reviewed for accidents and supervision. 1. The facility failed to supervise Resident #2 from assaulting Resident #3 when CNA D left the memory care unit to get additional staff to assist with Resident #2 on 08/27/25. Resident #3 suffered bruising to her face and forearm. 2. The facility failed to provide sufficient supervision on the secured unit to provide timely assistance to Resident #1 after he fell. Resident #1 fell at midnight on 06/21/25 and remained on the floor until 4:58AM. He sustained bruising to his left side area. This deficient practice was identified as past non-compliance. The Immediate jeopardy began on 06/21/25 and ended on 06/24/25, then began on 08/27/25 and ended on 08/28/25. The facility had corrected the non-compliance before the survey began. This deficient practice had the potential to affect all residents in the building by causing resident injuries, such as falls, fractures, and even death due to improper supervision. Findings included:1. Record review of Resident #2's face sheet, dated 08/27/25, reflected he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included anxiety disorder (a group of mental health conditions characterized by excessive worry, fear, and nervousness that can interfere with daily life) and depression (a serious mood disorder that affects how a person feels, thinks, and acts, causing persistent feelings of sadness or a loss of interest in activities). Record review of Resident #2's quarterly MDS assessment, dated 07/30/25, reflected he had a BIMS score of 02, which indicated severe cognitive impairment. He exhibited behaviors of wandering, and the wandering placed him at significant risk of getting to a potentially dangerous place. He also exhibited behaviors of rejection of care. Record review of Resident #2's Incident Case Report, dated 08/27/25, reflected LVN E wrote the report and CNA D observed the incident. The comments section of the report reflected This [Resident] went into another [Resident's] room with a commode plunger and hit a [resident] across the face causing bodily injury. This [resident] also hit nurse in face with plunger and with a [stethoscope] in nurse side. This [resident] also went into another [resident's] room with plunger and this nurse was able to get plunger from him and the CNA gently sat [resident] on the floor. [Resident] sat there [a bit] and got up with his fist balled up at this nurse. This nurse talked [resident] into walking to the other end of hall. The only way [resident] would go was that he commanded nurse to walk in [front] of him and he followed with his fist balled up. This nurse got [resident] to [sit] down on couch and he sat there a bit. He then got up and as he did the officer walked in. [Resident] asked, who was that and what did they want. This nurse explained that an officer had come to help. Another comments section reflected: sent to [Emergency Room] .for behavioral evaluation and placement. Immediate discharge notice for resident requested. Record review of Resident #3's face sheet, dated 08/27/25, reflected she was a [AGE] year-old Page 1 of 8 676051 676051 11/05/2025 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some female, admitted to the facility on [DATE]. Her diagnoses included dementia (a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life), major depressive disorder (a mental health condition characterized by persistent sadness, a loss of interest in activities, and feelings of hopelessness, which can impact daily functioning), anxiety disorder (a group of mental health conditions characterized by excessive worry, fear, and nervousness that can interfere with daily life), and Alzheimer's disease (a progressive brain disorder that causes memory loss, confusion, and other cognitive decline). Record review of Resident #3's quarterly MDS assessment, dated 06/24/25, reflected that she had a BIMS score of 03, which indicated severe cognitive impairment. She did not exhibit behaviors of rejection of care or wandering. Record review of Resident #3's Incident Case Report, dated 08/27/25, reflected LVN E wrote the report and CNA D observed the incident. The comments section of the report reflected This [Resident] was hit in the face, unwitnessed by another [resident] with a plunger. [Resident] came out of room with plunger and this [Resident] was hollering and crying. This nurse stayed to console [resident] and the other nurse went to call [Emergency Medical Services] and the police department. NO vitals were obtained due to the distress of the [resident]. Another comments section reflected: returned from [Emergency Room] without any major injuries. Continue neuro checks. Social to follow up with resident. refer to [external psych services company]. Record review of Resident #3's Head to Toe Skin Check, dated 08/27/25 at 02:39 PM, indicated she had bruising to her left eyebrow, right eye, left eye, tip of nose, left nostril, left jawline, top of right lip, under her right lip, and her left forearm. The form was signed by LVN F. Record review of Resident #3's progress notes, dated 08/27/25 through 08/29/25, reflected the following notes:*On 08/27/25 at 05:44AM, LVN E wrote 3 am [approximately] at this time this nurse was summoned to memory care to this [Resident's] room. [Resident] lying in bed crying help me, help me. [Resident] right eye swollen almost shut. Nose swollen. Left eye is swollen. [The DON] was notified. [LVN G] came to nurse station and called [emergency medical services] and police dept.Officer had staff leave room and he took pictures of [resident] and then came out. [Emergency medical services] here and transported [resident] to [hospital] for [evaluation] and [treatment].[Resident] distraught and would not be still for vital signs.*On 08/27/25 at 06:51PM, LVN F wrote Resident returned to facility via transport. [Neuro checks] started at arrival to facility. [vital signs within normal limits], [care of] pain to [right] side of head, scheduled [pain medication] administered, noted to be effective. Clear speech noted and movement in all 4 extremities noted. Bruising noted to [left] eye, [right] eye, left side of jawline, [left] forearm, above [left] eyebrow, tip of nose, top of right side of lip, under lip on right side, [left] nostril. Residents noted to be tearful throughout shift. Resident stated is the man coming back, resident reassure that she is safe, and the man is not coming back. Resident refused [morning] medications from the [medication aide], attempted multiple times to administer, resident states I want y'all to leave me [alone]. [new order] consult for [external psych services company] *On 08/28/25 at 05:11AM, LVN B wrote Resident rested in bed this [night]. [Neuros and vital signs] continue [within normal limits]. Resident continues to ask staff if the man is coming back. Resident re-assured that the man would not be coming back. Resident also voices concern about where the man is. Explained to resident that the man is no longer in the building. Bruising continues with no changes noted. *On 08/28/25 at 08:08AM, the Social Worker wrote [social worker] met with resident following incident. Resident was asked if she was hurting, and she stated yes her head hurts. [social worker] asked if she knew what happened and what was causing her pain, she stated yes, she was slapped by a man. She stated that she did not know why he was hitting her, stated that she was sick often. [Resident] stated that she was scared and did 676051 Page 2 of 8 676051 11/05/2025 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some not want that man near her. [social worker] reassured resident that he will not be back and that we will do everything we can to keep her safe. *On 08/28/25 at 08:25AM, the Social Worker wrote Met with resident again this morning, [resident] face has noticeable bruising around eyes. Was very vigilant/addled during conversation. States that he beat the hell out me night before last. [Resident] completed PTSD screen and answered yes that [she] was extremely frightened to most questions scoring 55. Spoke with her [family member] on 08/27 following event and he agreed to have her see a psychologist.Referral has been sent. *On 08/28/25 at 03:05PM, the Social Worker wrote Family requested referral documents to be sent to [another nursing facility]. *On 08/28/25 at 05:46PM, LVN F wrote Resident in common area, eating dinner. Continues on [neuro checks] [and vitals within normal limits]. A few episodes of tearfulness noted, resident states the man hit her with a shovel. Resident's stated, is the man coming back, resident reassure that she is safe and the man is not coming back. Color change to bruising noted. *On 08/29/25 03:56AM, LVN B wrote Resident resting in bed with eyes closed. Resident mentioned the man 2 times during shift but was assured he was not coming back and resident assisted to [bed] without difficulty. *On 08/29/25 at 05:09PM, LVN H wrote [staff] from [other nursing facility name, address, phone number] arrives at facility to pick up resident. meds, [belongings] sent with resident. report called to [other nursing facility].Resident pleasant. Wheel to vehicle and helped to load resident in vehicle. Resident discharged . At approximately [01:46PM]. Record review of a provider investigation report regarding the incident between Resident #2 and Resident #3, dated 09/02/25, reflected:Alleged Perpetrator: [Resident #2]Witness: [CNA D]Description of the Allegation: It is alleged that [Resident #2] went into [Resident #3's] room at approximately 3:00am and hit [Resident #3] several times while she was lying in bed. The alleged abusive incident was not witnessed. [Resident #2] hit a nurse with the plunger and a stethoscope that the nurse had laid down on the rail when she attempted to redirect resident from entering another resident room.Description of the assessment: [Resident #3] was noted to be crying when assessed by Charge Nurse after incident. [Resident #3's] right eye was swollen almost shut. Nose swollen and left eye is swollen. [Resident #3] was transported via [Emergency Medical Services] to [Emergency Department] for further assessment and treatment. No serious injuries were noted after visit. Follow-up by Social Services was completed. [Resident #3] returned to facility via transport. Neuros started at arrival to facility. [vital signs within normal limits], [care of] of pain to [right] side of head, scheduled [pain medication] administered, noted to be effective. Clear speech noted and movement in all 4 extremities noted. Bruising noted to [left] eye, [right] eye, left side of jawline, [left] forearm, above [left] eyebrow, Tip of nose, Top of right side of lip, under lip on right side, [left] nostril. [Resident #3] noted to be tearful throughout shift. [Resident #3] states is the man coming back, [Resident #3] reassured that she is safe, and the man is not coming back.Investigation Summary: CNA reported that [Resident #2] woke up and came out of his room and saw her seated in the commons area outside his room. He stated, I'm about to whoop your [a*s]. She attempted to respond calmly to him to ask what was wrong. He then turned and proceeded up the hall toward the Memory Care doors. CNA took this opportunity to move past him quickly and get to the door to go get a nurse to assist her with him and assess him. There were no other residents in the hall, and CNA stated during interview that at that time he had nothing in his hands. CNA stated that when she ran to the nurse's station to report to the nurse, they heard yelling from the [memory care] hall. The CNA went to respond, followed quickly by the two nurses on duty. [Resident #2] was seen in his underwear and very agitated with a plunger in his hand in the hall outside [Resident #3's] room. Nurses [LVN E and LVN G] were able to get past [Resident #2] to attend to [Resident #3]. They stated that [Resident #2] attempted to get back in the room, but that 676051 Page 3 of 8 676051 11/05/2025 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some they closed the door so they could check on [Resident #3]. [one of the nurses] then went out of the room to assist CNA with [Resident #2} who had proceeded toward the next room down on the left. When [the nurse] attempted to redirect him from entering the room he swung the plunger and hit her in the face and grabbed a stethoscope that she had laid on the handrail and hit her with it. At this time, CNA took [Resident #2] by the arm and laid him down gently to the floor. After getting up, they were able to redirect him to the end of the hall and keep him in that area until the police arrived.It is probable that [Resident #2] found the plunger in [Resident #3's] bathroom. It is not known whether [Resident #2] hit [Resident #3] with the plunger because no one witnessed [Resident #2] actually hitting [Resident #3]. But [Resident #3] has stated several times during follow-up assessments that that man came into my room and hit me. However, she has stated that he hit her with his hand at one time and at another time stated that he hit her with a shovel.Chart review for [Resident #2] reveals no prior aggressive behavior toward other residents. [Resident #2] has a BIMS score of 2. At time of incident when interviewed by Administrator, [Resident #2] had no recollection of what had occurred. Record review of a statement provided by the Administrator, dated 08/27/25, related to the incident between Resident #2 and Resident #3 and reflected: On the morning of 8/27/25 I received a call from [the DON] at 3:11am that we had a resident to resident altercation that resulted in one of the residents being beaten with a plunger by another resident on our Memory Care hall. I arrived to the facility at approximately 3:40am. When I went into the facility the resident who had allegedly been hit by the other resident was already loaded in the ambulance. [city] Police Department was on the scene. I went into the Memory Care unit and went to the dining room. The resident who had allegedly abused the other resident was sitting calmly in the dining room in a recliner. I went over to him and sat down next to him and asked him if he was doing alright. He said that he was and that he was glad that they were here, pointing over to the [city] Police officer who was standing in the dining room. I asked him if he knew what had happened, and he said that he didn't really, but he was just glad to get them off of him. I asked him what he meant by that, and he stated, I don't really know.I don't know what I am talking about. He remained calm while I talked with him, and when I asked him if he remembered anything that had happened, he said, No.what happened? and then asked me who I was. At this time [Emergency Medical Services] came in to transport him for evaluation. He stated that he didn't need to go and that he was fine. I told him that there had been an incident with him and another resident, and he needed to get checked out. He didn't want to go, but after the [Emergency Medical Services] person talked to him, he willingly got in the stretcher and was transported to [local hospital Emergency Department]. Record review of a statement written by LVN G, dated 08/27/25, reflected: 08/27/25 at 3:00AM memory care [CNA D] came out of memory care, was looking for [LVN E]. [CNA D] reports to this nurse that one of the resident's has been having aggressive behaviors [and] needs the nurse to come [and] assess, about that time, we heard hollering [and] someone crying. [CNA D] turns [and] runs to memory care unit, [and] this nurse looks down halls to check if [LVN E] was close by [and] then follows to memory care unit. Upon entering unit, noted [Resident #2] standing in hallway wearing only his underwear [and] holding a plastic plunger in the air. [CNA D] reports that [Resident #2] had been in [Resident #3's] room [and] had hit her [with] the plunger. This nurse goes to assess [Resident #3] injuries [and] [LVN E] arrives to [Resident #3's] room at that time. While we were in [Resident #3's] room, [Resident #2] returned to the doorway [with] plunger in the air [and] trying to come back into [Resident #3's] room. [Resident #2] swings plunger at me [and] [LVN E] [and] misses [and] tells us to get out. At that point I believe [CNA D] was able to re-direct [Resident #2] to allow this nurse to get out of [Resident #3's] room [and] get back to nurse's station to call 676051 Page 4 of 8 676051 11/05/2025 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some 911 per [the DON's] [advice]. Record review of an undated statement written by LVN E reflected: [Resident #2] hit me to [right] side face - he was in [another resident's] room - he chased out [with] plunger and hit. He had already been in [Resident #3's] room and hit her in the face. He walked over to wall and grabbed [stethoscope] this nurse had laid down and hit this nurse inside. The [CNA D] then gently sat [Resident #2] on floor. The [resident] then got up and charged this nurse again [with] fist balled up. Was able to coax [resident[ to other end of hall if I walked in front of him and he had his fist balled up the whole time. He sat down on the couch and as he got up to chase again the police came in. He had already hit [Resident #3] when I came back to memory care. At one point [Resident #2] had me barricaded in [Resident #3's] room. Record review of a statement, dated 08/27/25, written by CNA D reflected: On 08-27-25 at around 3:05AM [Resident #2] woke up aggressively and came out of his room pointed at me and said, I'm about to whoop you're a*s. I calmly asked him what was going on and he proceeded to walk down the hall. That's when I ran to the nurse's station to tell the nurse that he was really aggressive and needed someone to come back there to the unit. Like 8 seconds later I heard [Resident #3] hollering stop, please stop. So, me, [LVN G], and [LVN E] all ran back to the memory care unit and [LVN G] [and] [LVN E] tried to redirect him. That's when he started swinging the plunger at them. He came out of that room and directed his aggression towards [LVN E] and hit her in the face with the object. After that he started to walk in [another resident's] room and that was when I grabbed his arm and gently laid him on the floor. He got back up and I told him to stop and that he's not about to keep hitting on these women. He kind of calmed down after I said that and I walked him to his room. I told him to stay in there because he had already hurt [Resident #3] badly. That's when he said OK, I'm sorry and he stayed down by his room until the police arrived. 2. Record review of Resident #1's face sheet, dated 06/27/25, reflected he was an [AGE] year-old male, admitted to the facility on [DATE]. His diagnoses included Parkinson's disease (a progressive movement disorder of the nervous system) and benign prostatic hyperplasia (a common non-cancerous enlargement of the prostate gland that occurs with age and can cause lower urinary tract symptoms). Record review of Resident #1's admission MDS assessment, dated 06/16/25, reflected he had a BIMS score of 10, which indicated moderate cognitive impairment. He required moderate assistance with sit-to-stand transfers, bed-to-chair transfers, and walking 10 feet. Walking 50 feet with two turns and walking 150 feet was not attempted due to medical condition or safety concerns. The resident was completely dependent on staff for bending down from a standing position to pick up a small object. He was frequently incontinent of both bowel and bladder. He had a fall in the 2-6 months prior to admission. He had two or more falls with no injury at the time of this MDS assessment. Record review of Resident #1's care plan, printed on 06/27/25, reflected a care area of fall risk, related to falls on 06/10/25, 06/11/25, 06/14/25, 06/17/25, and 06/21/25. The care plan reflected he was a high risk for falls (onset 06/10/25). The goals included resident will verbalize understanding of the need for assistance over the next 90 days. Interventions included the following:*06/10 call before you fall sign*06/11/25 dycem (a non-slip material used to keep a wheelchair cushion in place in a wheelchair) placed under wheelchair cushion*06/14/25 anti-roll back device to wheelchair*06/17/25 padded call light to bedside*06/21/25 brightly colored call before you fall sign placed in multiple areas in line of sight for increased visual reminder to use call light for assistance. Contrast color on bathroom call light cord to aid in identifying use*Assist resident with ADLs as needed*Assist resident with toileting as needed*Keep call light and most frequently used personal items within reach*Remind residents to call when needing assistance*Wheelchair.The care plan further reflected a care area of impaired physical mobility. This care area reflected the following areas Resident #1 required 676051 Page 5 of 8 676051 11/05/2025 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some assistance:*Supervision or touching assistance with sitting to lying transfers*Supervision or touching assistance with lying to sitting on side of bed transfers*Moderate assistance with sitting standing transfers*Moderate assistance with chair to bed transfers*Moderate assistance with wheeling 50 feet with 2 turns*Supervision or touching assistance with toilet transfers Record review of Resident #1's Neuro Check form, dated 06/19/25 through 06/22/25, reflected the following 4 neuro checks and vital signs documented:*On 06/21/25 at 05:00AM, Resident #1 was alert, pupils were equal and reactive to light. Resident #1 had equal hand grasps and was able to move all extremities. His vital signs were blood pressure of 148/70, temperature of 98.1 deg F, pulse 79, and respirations 18. This was documented by LVN B at 5:13AM.*On 06/21/25 at 05:15AM, Resident #1 was alert, pupils were equal and reactive to light. Resident #1 had equal hand grasps and was able to move all extremities. His vital signs were blood pressure of 143/75, temperature of 98.1 deg F, pulse 77, and respirations 18. This was documented by LVN B at 5:22AM.*On 06/21/25 at 05:30AM, Resident #1 was alert, pupils were equal and reactive to light. Resident #1 had equal hand grasps and was able to move all extremities. His vital signs were blood pressure of 141/79, 98.2 deg F, pulse of 74, respirations of 18. This was documented by LVN B at 6:03AM.*On 06/21/25 at 05:45AM, Resident #1 was alert, pupils were equal and reactive to light. Resident #1 had equal hand grasps and was able to move all extremities. His vital signs were blood pressure of 146/82, 98.0 deg F, Pulse 77, respirations of 18. This was documented by LVN B at 06:04AM. Record review of Resident #1's progress note, dated 06/21/25, signed by LVN B at 05:12AM, reflected: [05:00AM] Noted resident on floor in room. Resident stated he walked to the restroom and was walking back when he lost his balance and fell. No injuries noted. Moves all extremities without difficulty. [Neuro checks and vital signs] initiated. Record review of Resident #1's Skin Data form, dated 06/21/25, reflected he had bruising to his buttocks and left buttocks. He also had a quarter sized abrasion to left upper outer chest wall under arm. This form was signed by LVN C on 06/21/25 at 01:20PM. Record review of a Provider investigation report regarding Resident #1's fall incident, dated 06/27/25, reflected:Alleged Perpetrator: [CNA A]Description of the allegation: Resident was found on the floor of his room at approximately 4:30am by CNA. CNA notified nurse who notified resident's [family member]. [Family member] reviewed footage of camera in room and saw that resident fell at 12:00am. There was no evidence on the camera that resident was rounded on by CNA between midnight and 4:30am when he was found.Description of assessment: Skin assessment by charge nurse - quarter sized abrasion to left upper outer chest wall under arm (did not voice pain when touched) - treatment provided; Pain assessment x2 with no pain expressed by resident. Follow-up assessment by Administrator on 6/24/25 with no noted emotional distress from the event. Social Service Assessment on 6/27/25 by Social Service Director - no emotional distress noted - resident feels safe in facility.Investigation Summary: Upon interview, CNA stated that she helped the resident to bed around 10pm. She stated that she did a visual check on him between 10:00pm and 12:00am, and he was in bed sleeping. This did not appear on the camera because she just opened the door and could see him from the door. The camera does not have the door in view and only comes on with motion. CNA acknowledged that she did not check on him between 12:00am and 4:30am when she found him because she was having difficulty with another resident and got overwhelmed .and I guess I just forgot to look in on him. Charge nurse stated that she had checked on the CNA through the night and she did not indicate that she was having any trouble. She had been on the hall and seen this resident earlier in the night but did not see him between the hours of 12:00am and 4:30 when the CNA came to get her. Record review of an undated statement, written by CNA A, reflected: I [CNA A] put [Resident #1] to bed around 9 something. I checked on him around 11:45[PM] he was in bed looking at T.V. but the camera [does] not show that. 676051 Page 6 of 8 676051 11/05/2025 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some The lights were on in his room. I can see him from the door. I leave off me to start my round - I am still on my hall, but I am on the outside of the doors. I was told that I had that section of the hall outside the doors. I left that resident room to get diapers out of supply room on B hall. I take care of all [residents] on that hall. I go back over to [memory care] to start my [round] over there around 12:15[AM] [starting] with my female resident first. I am working my way down the hall I check my next resident. [Another resident] is my third resident. He is sitting at the end of the hall [at] 1:00AM. I came in and smelled poop. He was naked from way down had poop all over his legs he is rubbing it up and down his legs. Poop was all over the floor, chairs and wall. I take him to the shower to clean him up. We are in the shower for 30 minutes to 35 minutes. I go back down the hall to clean all of the poop up.After that I take break because I am overwhelmed by all of the poop I had to clean up. I clock out at 2:07[AM] I come to my hall I clean up shower room. I clock back at 2:45[AM] I come back to my hall [another resident] is naked again in the hallway in front of his room with poop on floor, door, bed and he has it in his hand. [it is 3:00AM] we go back to shower it a little harder this time around he is given some resistance. I get him clean up again I clean up the poop off of bed, floor, and door. I took him to the dining room. I come out of dining room my female resident is her door with no pull up on. I get her clean and back in bed this around [4:00AM] I make it to [Resident #1's] room. I open the door he is on the floor I see he is not [bleeding]. I told him I have to go get the nurse he is not in distress he [understood] what I said. I close the door to give him privacy. I leave the hall to [find] the nurse. I go down B hall I ask another CNA do she know [where] the nurse is she said no I go to the smoker area she is not there. I came back in, and she was at the nurse station. I tell her [Resident #1] is on the floor. We go back to his room we get up off the floor. I put him back in bed I put call light on table urinal on table searched for his remote it was under the bed put it on table I let him know everything is on table I leave out of the room. During an observation of a video recording from a camera in Resident #1's room, dated 06/21/25, this surveyor observed the following:*on 06/20/25 at 9:32PM, CNA A entered Resident #1's room, straightened his bed, assisted him to find a show to watch, and then transferred him to bed.*From 9:37PM to 9:42PM, CNA A further straightened Resident #1's sheet and blanket, moved his bedside table beside his bed, put his call light within reach, and then left the room. His wheelchair was placed out of his reach on the other side of the room.*At 10:50PM, Resident #1 was sitting up on the side of the bed with his shoes on the floor.*At 11:39PM, Resident #1 stood up out of his bed, with his right hand on the bed, and his left hand on the bedside table.*At 11:42PM, Resident #1 walked with an unsteady gait, towards the doorway to his room.*On 06/21/25 at 12:00AM (midnight), Resident #1 was standing at the doorway to his room. He moved his right foot back one step and fell backwards. As he was falling, his left arm and left rib cage hit a chair that was against the wall next to the doorway. He landed directly on his bottom and rolled to his right side on the floor.*From 12:03AM until 04:56AM, Resident #1 remained on the floor in his room. He was seen fidgeting his hands, taking off his shoes, attempting to put his shoes back on, and moving around his wheelchair and wheelchair cushion.*At 4:58AM, LVN B and CNA A entered Resident #1's room. Resident #1 was lying on his back with his legs flexed and his knees were pointed towards the ceiling. LVN B said Hello there, What happened?, and Are you hurt?. CNA A and LVN B both reached out to grab Resident #1's hands. They each grabbed one of his hands and pulled him up to his feet. Resident #1's arms were extended out in front of him as they pull him up to his feet. LVN B said Did you slip?, and Are you hurt?. LVN B and CNA A assisted Resident #1 into his wheelchair. LVN B left the room and CNA A assisted Resident #1 to his bed.*At 5:21AM, LVN B entered Resident #1's room. She cancelled the call light and asked Resident #1 did you 676051 Page 7 of 8 676051 11/05/2025 Briarcliff Skilled Nursing Facility 4054 Northwest Loop Carthage, TX 75633

F 0689 Level of Harm - Immediate jeopardy to resident health or safety Residents Affected - Some need anything?*At 6:54AM, an unknown CNA entered the room and offered Resident #1 a shower. The video ends.The video did not show any staff obtaining vital signs, conducting an assessment, or conducting a neuro check. During an interview on 11/03/25 at 10:15 AM, LVN B said she worked the night shift on 06/20-06/21. She said she saw Resident #1 around the time she was giving medications around 7:00PM and she did go back a little later around 9:30 PM to assist CNA A with incontinent care. She said there were two residents that were back there at the time that required two staff to clean them up at times. She said she did not check on Resident #1 between 9:30 PM and 5:00 AM. She said the aide is supposed to check on the residents every 2 hours. She said she did not think CNA A was busy. She said CNA A would usually come to get her if she was swamped and needed help. She said if CNA A had come and told her that she was swamped they may have found the resident before 5 AM. She said she went back to check on CNA A around midnight and she was sitting down in the dining area working on a laptop. She said CNA A came to get her around 05:00 AM to let her know Resident #1 had fallen. She said she went down there and checked on him and he did not complain of pain. She said they picked him up and she asked CNA A to get a set of vital signs. She said she told CNA A to check Resident #1's vital signs a couple times. She said CNA A provided her with the vital signs written down and she charted them. She said she reviewed the video of the incident, and the video did not show CNA A obtaining any vital signs. During an interview on 11/03/25 at 10:28 AM, CNA A said she worked the night shift from 06/20/25 through 06/21/25. She said she was not aware the facility was staffed short that evening until the nurse came over and told her the assignment she had. She said there has never been two aides assigned to the unit. She said she was assigned that evening the entire hallway including the rooms just outside the memory care unit. She said there are three resident rooms that are in the same hall as the memory care unit, but they are outside the memory care secured doors. She said Resident #1 was sitting up in his wheelchair with her until she put him to bed. She said she started her rounds after putting Resident #1 to bed. She said she remembered she started at the end of the hall outside the unit around 12:00 AM. She said as she came down the hall a resident was standing naked at her doorway. She said her focus was on helping the resident and getting her covered. She said she got down to the next room and smelled poop. She said another resident was standing in the hallway rubbing poop all over the place. She stopped to help that resident and clean him up and clean the area. She said somewhere wh 676051 Page 8 of 8