Below average — CMS composite of the measures below.
A standard survey is most likely before around August 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Briarcliff Health Center during CMS and state inspections, most recent first.
The facility failed to provide scheduled showers for four residents, impacting their personal hygiene and quality of life. Despite being scheduled for showers multiple times a week, records showed inconsistencies in the provision of these showers. Interviews with staff revealed that showers were documented on sheets, which were not always completed, making it difficult to prove that showers were given.
The facility failed to coordinate hospice care and ensure proper documentation for three residents receiving hospice services, leading to potential risks in end-of-life care. Interviews revealed that the DON did not regularly check hospice binders, and the Administrator was not involved in clinical matters.
The facility failed to maintain clean beverage service equipment in the ABC halls common dining area, with the ice machine, ice dispenser, and coffee and iced tea dispensers found dirty with black, slimy scum, and rust build-up. Dietary staff were inconsistent in their cleaning responsibilities, and the cleaning schedule did not include the tea dispenser.
The facility failed to ensure accurate PASRR screenings for two residents with mental health disorders, leading to a lack of necessary evaluations and specialized services. Both residents had documented mental health diagnoses and were receiving related medications, but their PASRR Level 1 Screenings inaccurately indicated no evidence of mental illness.
A CNA at the facility failed to respect a resident's refusal to be transferred, using force and intimidation to move her against her will. The resident experienced pain and mental anguish during the incident, which was confirmed by video evidence and family reports. The CNA was subsequently blocked from returning to the facility.
The facility failed to ensure a resident was treated with dignity and respect, resulting in a resident being urinated on by his roommate for two consecutive nights. Despite being aware of the first incident, the staff did not relocate the offending resident, leading to a second incident and causing the affected resident to feel humiliated and dehumanized.
A resident with severe cognitive impairment and multiple diagnoses was discharged without proper notification or planning. The family was abruptly informed to pick up the resident, who was initially supposed to be transferred to a behavioral hospital but ended up spending 24 hours in the ER due to lack of prior arrangements. The facility failed to follow proper discharge procedures and did not communicate effectively with the receiving provider.
A resident with severe cognitive impairment and multiple diagnoses was admitted to the facility despite being a registered sex offender, which was against the facility's admission criteria. The resident was discharged shortly after admission when the facility became aware of his status, leading to distress for the family. Interviews with staff confirmed that the facility's policy prohibited the admission of sex offenders, and an in-service training was conducted to reinforce the policy.
Failure to Provide Scheduled Showers for Residents
Penalty
Summary
The facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene. Specifically, the facility did not provide scheduled showers for four residents, which could place them at risk of not receiving essential care and decreased quality of life. The report highlights that these residents were scheduled for showers multiple times a week, but records indicate that these showers were not consistently provided. Resident #1, a female with Alzheimer's disease and severe cognitive impairment, was scheduled for showers on Mondays, Wednesdays, and Fridays. However, the facility's records for July and August 2024 showed that she did not receive showers as scheduled, except for one instance on August 12, 2024. Similarly, Resident #2, a male with Alzheimer's disease and muscle wasting, was scheduled for showers on the same days but only received a few showers during the same period. The records for Resident #3, a female with Alzheimer's disease and severe cognitive impairment, also indicated a lack of showers despite being scheduled for Tuesdays, Thursdays, and Saturdays. Resident #4, a male with Alzheimer's disease and severe cognitive impairment, was also affected by this deficiency. He was scheduled for showers on Tuesdays, Thursdays, and Saturdays, but the records showed inconsistencies in the provision of these showers. Interviews with staff, including CNAs and the DON, revealed that showers were documented on shower sheets, which were not always completed or turned in, making it difficult to prove that showers were given. The facility's procedures emphasized the importance of personal hygiene and skin integrity, but the lack of documentation and adherence to schedules led to the deficiency.
Failure to Coordinate Hospice Care and Documentation
Penalty
Summary
The facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for residents receiving hospice services. Specifically, the facility did not ensure that the hospice skilled nurse progress notes for three residents were included in the resident records. This lack of documentation and coordination could lead to inadequate end-of-life care for the residents involved. Resident #1, a female with Alzheimer's disease, pain, dementia, and anxiety disorder, was receiving hospice services. However, her hospice binder contained only one skilled nurse note, despite the care plan indicating weekly visits. Similarly, Resident #2, a female with COPD, chronic respiratory failure, dementia, abnormal weight loss, and stroke, had only one skilled nurse note in her hospice binder, even though her care plan required more frequent visits. Resident #3, a female with dementia, senile degeneration of the brain, abnormal weight loss, and diabetes, also had incomplete documentation in her hospice binder. Interviews with facility staff revealed that the Director of Nursing (DON) did not regularly check the hospice binders and relied on the hospice provider to ensure all necessary paperwork was included. The Administrator expected the hospice binders to contain all relevant information for continuity of care but was not involved in clinical matters. The facility's Hospice Care policy emphasized the importance of documentation for palliative care, but this was not adhered to in practice.
Failure to Maintain Clean Beverage Service Equipment
Penalty
Summary
The facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety in the ABC halls common dining area. Specifically, the large ice machine, ice dispenser, and coffee and iced tea dispensers were found to be dirty with black, slimy scum, and rust build-up. These unsanitary conditions were observed on multiple occasions, indicating a lack of proper cleaning and maintenance. Interviews with dietary staff revealed that there was confusion and inconsistency regarding the responsibility for cleaning these machines, and the cleaning schedule did not include the tea dispenser. The dietary manager acknowledged the oversight and mentioned that the cleaning schedule form had been changed by the new company, which led to the beverage bar being left off the schedule. The facility's undated sanitation policy stated that ice machines and storage containers should be cleaned and sanitized per the manufacturer's instructions, and the coffee area should be cleaned daily. However, these guidelines were not followed, as evidenced by the observations and interviews. The FDA Food Code 2022 also requires that food-contact surfaces and equipment be kept clean to sight and touch, and nonfood-contact surfaces be free of dust, dirt, food residue, and other debris. The failure to adhere to these standards could place residents at risk of being served in unsanitary conditions and for foodborne illness.
Inaccurate PASRR Screenings for Residents with Mental Health Disorders
Penalty
Summary
The facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screening for two residents. Resident #17, a female with diagnoses including dementia, mood disorder with depressive features, depression, and major depressive disorder, had a PASRR Level 1 Screening that inaccurately indicated no evidence of mental illness. Despite receiving antidepressant medication and having a diagnosis of depression documented in her MDS assessment, the necessary follow-up actions were not taken to ensure an accurate PASRR evaluation and appropriate services for her mental health needs. Similarly, Resident #92, a female with diagnoses including psychotic disorder with delusions and bipolar disorder, also had a PASRR Level 1 Screening that inaccurately indicated no evidence of mental illness. Her MDS assessment documented her diagnosis of bipolar disorder and the use of antipsychotic medication, yet the facility failed to notify the state designated authority and ensure an accurate PASRR evaluation. The MDS Nurse acknowledged the oversight and the importance of accurate PASRR screenings to ensure residents receive the correct resources and specialized services.
Resident Abuse by CNA
Penalty
Summary
The facility failed to ensure a resident had the right to be free of abuse. A CNA refused to take no for an answer when a resident expressed she did not want to be transferred. The CNA pushed back at the resident's flailing hands, reached under her arms, and transferred her against her will from her wheelchair to her bed. The resident complained of back pain during the transfer and was subjected to loud, intimidating behavior from the CNA, who was close to the resident's face and hollering at her. The CNA also reached between the resident's legs to check if she was wet, despite the resident's pleas for her to stop. The resident involved was an elderly female with severe cognitive impairment, requiring substantial assistance with transfers. Her care plan indicated that she should not be forced to perform care activities and that her family should be called for assistance with ADL issues. On the day of the incident, a family member reported the CNA's rough and rude behavior to the facility staff. The facility's investigation confirmed the family member's account, and the CNA was blocked from returning to the facility. Video evidence provided by the family showed the CNA's aggressive and intimidating behavior towards the resident. The CNA was seen loudly questioning the resident's refusal to be transferred, pushing the resident's hands out of the way, and lifting her to the bed against her will. The CNA's actions caused the resident to experience pain and mental anguish. Interviews with facility staff confirmed that they were aware of the facility's abuse policy and the resident's right to refuse care, but the CNA's behavior was found to be abusive and in violation of the resident's rights.
Failure to Ensure Resident Dignity and Respect
Penalty
Summary
The facility failed to ensure a resident was treated with dignity and respect, resulting in Resident #3 being humiliated due to Resident #2 urinating on him for two consecutive nights. On the first incident, which occurred on 3/30/24, Resident #2, who had severe cognitive impairment and was known for frequent falls and restlessness, urinated and defecated on Resident #3's side of the room. Despite being aware of this incident, the staff did not relocate Resident #2, citing a lack of available rooms on the same unit and the need for administrative approval to move him to another unit. Consequently, a second incident occurred on 3/31/24, where Resident #2 again urinated on Resident #3 and his belongings. Resident #3, who was cognitively intact but had functional limitations due to a stroke, expressed his distress and requested that Resident #2 be moved after the first incident. However, he was told to wait until the Administrator returned on 4/1/24. During this period, Resident #2 was monitored at the nurse's station during the day but was allowed to stay in the room at night, leading to the second incident. The staff's inaction and failure to promptly address the situation resulted in Resident #3 feeling humiliated and dehumanized. Interviews with various staff members, including the ADON, CNA, LVN, and the Administrator, revealed that they were aware of Resident #2's behavior and the incidents but did not take immediate action to prevent a recurrence. The facility's Resident Rights policy emphasizes the importance of treating residents with respect and dignity, which was not upheld in this case, leading to the deficiency.
Improper Discharge and Lack of Preparation for Resident Transfer
Penalty
Summary
The facility failed to provide and document sufficient preparation and orientation to ensure a safe and orderly transfer or discharge for a resident. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and Parkinson's disease, was discharged without proper notification or planning. The family was abruptly informed to pick up the resident, who was initially supposed to be transferred to a behavioral hospital but ended up spending 24 hours in the ER due to lack of prior arrangements. The Director of Admissions claimed that the resident was admitted under false pretenses, as the family did not disclose that the resident was a registered sex offender. The resident exhibited major behavioral issues, including urinating and defecating on his roommate's belongings. Despite these behaviors, the facility did not follow proper discharge procedures. The family was misled into believing that the behavioral hospital was prepared to admit the resident, but upon arrival, the hospital staff had no knowledge of the resident's transfer. Interviews with various staff members revealed a lack of communication and documentation regarding the discharge process. The facility's discharge policy requires thorough documentation and communication with the receiving provider, which was not adhered to in this case. The resident's family was left to manage the situation without adequate support, leading to the resident being temporarily placed in the ER and eventually taken back home without a proper discharge plan.
Failure to Implement Admission Policy and Disclose Service Limitations
Penalty
Summary
The facility failed to implement an admission policy and did not disclose to a resident notice of special service limitations prior to admission. A resident was admitted to the facility despite being a registered sex offender, which was against the facility's admission criteria. The resident had severe cognitive impairment and multiple diagnoses, including dementia, unsteadiness on feet, repeated falls, adult failure to thrive, depression with anxiety, and Parkinson's disease. The resident was discharged shortly after admission when the facility became aware of his status as a sex offender, which was disclosed by a family member during a visit to the facility. The Director of Admissions claimed that the family did not inform him that the resident was a sex offender during the admission process. However, the family member stated that she had informed the Director and provided the contact information of the person the resident reported to. The facility's policy explicitly stated that they could not admit sex offenders, and the Director of Admissions admitted that the resident would not have been admitted if this information had been known. The situation led to the resident being discharged abruptly, causing distress to the family. Interviews with various staff members, including the Administrator, ADON, LVN, and RNC, confirmed that the facility's policy prohibited the admission of sex offenders. The Administrator and other staff members were unaware of the resident's status until it was disclosed by the family member. The facility conducted an in-service training to reinforce the admission policy and ensure that residents are checked on the relevant website prior to admission. The failure to adhere to the admission policy and the lack of proper communication led to the deficiency in the facility's admission process.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Tyler
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Azalea Heights | 0.2 mi | ★★★★★ | 11 | 1 |
| Reunion Plaza Healthcare & Rehabilitation | 1.4 mi | ★★★★★ | 0 | 0 |
| Providence Park Rehabilitation And Skilled Nursing | 2.4 mi | ★★★★★ | 1 | 1 |
| Meadow Lake Health Center | 2.5 mi | ★★★★★ | 0 | 0 |
| The Heights Of Tyler | 2.7 mi | ★★★★★ | 7 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.