Average — CMS composite of the measures below.
The next survey window likely opens around March 2027
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 Skilled Nursing Facility during CMS and state inspections, most recent first.
Incomplete Comprehensive Care Plans for Hospice, PTSD, Dialysis, and Combative Behavior: A resident on hospice, a resident with a PTSD history, a resident receiving dialysis, and a resident with rejection of care/combative behavior all had MDS findings or orders documenting those needs, but their comprehensive care plans did not include the related services, triggers, or interventions. Interviews with the ADON, family member, MDS Coordinator, DON, and Administrator confirmed these items should have been care planned and that the MDS nurse was responsible for the comprehensive care plans.
Failure to Invite Residents and Representatives to Care Plan Meetings: Two residents were not consistently included in quarterly care plan conferences. One resident with anemia, A-fib, cirrhosis, and moderate cognitive impairment said she had never been invited to a care plan meeting, and a second resident with Parkinson's disease had a family member who said she had not been invited in a while. The SW said she sent invitation letters and that some meetings may have been missed during a period when staffing was limited, while the DON and Administrator stated care plan meetings should occur quarterly with the resident, family, and IDT.
Unsafe and Unclean Resident Room Conditions: A cognitively intact resident with muscle weakness, chronic pain, and liver disease had a damaged bathroom door with black marks on the door and nearby wall, and dirty room windows that staff had noticed but not addressed. The resident said the conditions made her feel staff did not care, while interviews showed CNA, housekeeping, maintenance, LVN, and the DON were aware of the cleanliness and repair concerns or did not know who was responsible for them.
A resident with COPD, Alzheimer’s disease, and anxiety disorder was not kept free from physical restraint when a CNA held both wrists during a brief change after the resident became combative. The resident had moderate cognitive impairment and rejection of care, and bruising was later documented on both forearms. Interviews showed staff continued the care while holding the resident’s wrists in the air, and the DON and ADON stated staff should stop and return later when a resident becomes combative.
Baseline Care Plans Not Completed or Signed by RN: The facility failed to complete baseline care plans within 48 hours for two residents and did not ensure RN involvement in the process. One resident with heart block, atrial flutter, B-cell lymphoma, COPD, and DM2 had a baseline care plan that did not address a catheter, even though a drainage bag was observed and the resident said the catheter came from the hospital. Another resident with anemia, AFib, cirrhosis, and moderate cognitive impairment had no baseline care plan completed by the IDT including a RN, and said no baseline care plan meeting occurred on admission.
A resident with severe cognitive impairment and ADL dependence was not kept clean shaven despite stating that he preferred to be clean shaven. CNA documentation showed bathing/hygiene assistance, but it did not show shaving, and notes did not indicate any refusal. The resident had visible facial hair on repeated observations, and staff confirmed CNAs were responsible for shaving residents during showers as part of routine hygiene care.
A facility failed to prevent accidents and provide adequate supervision, resulting in one resident with severe cognitive impairment assaulting another resident and a separate incident where a resident at high risk for falls was left on the floor for several hours after falling. Both incidents involved lapses in staff monitoring and supervision, leading to resident injuries and distress.
A resident with cognitive impairment and Parkinson's disease suffered second-degree burns after spilling hot coffee served at an unsafe temperature. The facility lacked policies for monitoring hot liquid temperatures and did not conduct risk assessments for residents. Staff interviews revealed inadequate training and awareness regarding the safe serving of hot beverages, contributing to the incident.
The facility's kitchen failed to meet food service safety standards due to inadequate cleaning and maintenance. Observations revealed black carbon buildup on baking sheet pans and the stove top. Staff interviews indicated infrequent cleaning and a lack of clear responsibilities. The Dietary Manager acknowledged the issue, citing short staffing as a challenge. Maintenance records were incomplete, and the facility lacked a specific cleaning policy, leading to potential risks of foodborne illness and contamination.
The facility failed to maintain a system for the receipt and disposition of controlled drugs, risking medication loss and diversion. Controlled medications were stored in the DON's office without proper logging until destruction, contrary to policy. The Administrator was unaware of the narcotic medication policy, and the last medication destruction was not recent, indicating a lack of regular reconciliation.
A resident was found with unauthorized medications in her room, and two nurses left medication carts unlocked and unattended, violating facility policies. The resident had no order to self-administer, and the carts' unsecured state posed risks of unauthorized access and medication errors.
A facility failed to provide palatable and appetizing food at safe temperatures, affecting four residents. Complaints included bland, cold, and unsuitable food for dietary needs. Despite offering alternatives, dissatisfaction persisted. Staff interviews confirmed frequent resident complaints, and test tray evaluations revealed issues with food quality. The facility's policy on food temperatures was not effectively implemented.
A long-term care facility was found deficient in its infection prevention and control program. Staff failed to perform proper hand hygiene during wound care, used ineffective disinfectants for C. diff, and did not apply enhanced barrier precautions during medication administration and tracheostomy care. These lapses increased the risk of cross-contamination and infection spread among residents.
A resident with severe cognitive impairment and multiple diagnoses was found to be using a lap harness on a Broda chair without proper assessment, monitoring, or documentation as a restraint. Facility staff did not have a clear understanding of the harnesses' use, and there was no physician order or signed consent. Despite justifications for safety and mobility, the lack of documentation and policy on restraints led to a deficiency.
Two residents' MDS assessments failed to accurately reflect the use of restraints. One resident's safety vest and lap belt were not documented as restraints despite being used for positioning due to cerebral palsy. Another resident's limb restraint was not recorded, although it was used for safe positioning due to Rett's Syndrome. Staff and medical professionals considered these devices necessary for safety, but the facility's policy requires accurate assessments to ensure proper care.
A resident with COPD was consistently receiving oxygen at a higher rate than prescribed, contrary to physician orders. Observations showed the resident receiving 3.5 l/min instead of the ordered 2 l/min, and at one point, the setting was at 4 l/min. The LVN and DON confirmed the discrepancy, noting the electronic MAR did not prompt checks for as-needed oxygen settings. The facility's policy requires verification and documentation of oxygen flow rates, which was not followed.
Incomplete Comprehensive Care Plans for Hospice, PTSD, Dialysis, and Combative Behavior
Penalty
Summary
The facility failed to develop and implement comprehensive person-centered care plans with measurable objectives and timeframes for four residents whose assessments and records identified specific needs. Resident #2, a female admitted with anemia, atrial fibrillation, and cirrhosis, had an admission MDS showing a BIMS of 12, dependent assistance for bed mobility, personal hygiene, dressing, and transfer, and receipt of hospice services, but her comprehensive care plan dated 03/21/2026 did not include hospice services. Resident #3, admitted with dementia, diabetes type II, and bipolar disorder, had an admission MDS with a BIMS of 10 and a PTSD screen documenting a history of PTSD, but her comprehensive care plan dated 02/27/2026 did not include PTSD, PTSD triggers, or PTSD interventions. Resident #10, admitted with chronic kidney disease, end stage renal disease, and stroke, had a quarterly MDS showing intact cognition with a BIMS of 15 and indicating dialysis services, and an active physician order for dialysis every shift with monitoring of the shunt/graft/fistula for signs or symptoms of infection and adequate circulation, but the care plan dated 03/31/26 did not include dialysis services. Resident #30, admitted with COPD, Alzheimer’s disease, and anxiety disorder, had a quarterly MDS showing a BIMS of 08 and a behavior of rejection of care, but the care plan dated 03/31/26 did not include her history of resisting care or combative behavior. During interviews, the ADON stated Resident #30 refused care and could be combative, and the family member said she became combative if awakened or made to do something she did not want to do. The MDS Coordinator stated care plans were to include all items coded on the MDS, including hospice services, PTSD, dialysis, behaviors, and diagnoses, and that not care planning important items could result in staff not knowing what was needed for management of the resident’s condition. The DON and Administrator stated major diagnoses, conditions, medications, falls, and individualized interventions should be care planned, and the Administrator stated the MDS nurse was responsible for creating comprehensive care plans.
Failure to Invite Residents and Representatives to Care Plan Meetings
Penalty
Summary
The facility failed to ensure residents and/or their representatives were invited to participate in the development and implementation of person-centered care plans for 2 of 18 residents reviewed. One resident was a female admitted with anemia, atrial fibrillation, and cirrhosis, and her admission MDS showed a BIMS score of 12, indicating moderate cognitive impairment. She required dependent assistance for bed mobility, personal hygiene, dressing, and transfer. Record review showed no documentation of care plan meetings completed prior, and during interview she stated she had not been invited to or participated in a care plan meeting and wanted to attend so someone could explain her medical condition to her. The second resident was a male admitted with Parkinson's disease. His quarterly MDS showed unclear speech, that he was usually understood and sometimes able to understand others, and a BIMS score of 11, indicating moderately impaired cognition. He usually required partial/moderate to substantial/maximal assistance for most ADLs. A quarterly care conference form showed one care conference was conducted and that the resident representative was invited and attended, but no additional care plan conference forms were available. The resident's family member stated she had attended a care plan meeting when he first admitted but had not been invited to a care plan meeting in a while, and she would have liked to attend and participate in his care plan meetings. The Social Worker stated she was responsible for keeping a calendar and ensuring care plan meetings occurred at least quarterly, and that she sent letters to families to invite them. She also stated there was a period when a part-time social worker was trying to do all care plan meetings and that some meetings may have been missed. The DON and Administrator stated care plan meetings should occur quarterly, involve the interdisciplinary team, and include the resident and family, and the facility policy stated the interdisciplinary team would coordinate with the resident and legal representative and review the care plan quarterly and annually.
Unsafe and Unclean Resident Room Conditions
Penalty
Summary
The facility failed to provide a safe, functional, sanitary, and comfortable environment for Resident #32. The resident’s face sheet showed diagnoses including muscle weakness, chronic pain, and liver disease, and the MDS indicated she was cognitively intact with a BIMS score of 14 and required dependent staff assistance for most ADLs. During observation, the inside of the bathroom door in her room had a deep scrape and black marks along the bottom of the white door and door frame, and there were black marks along the wall near the floor outside the bathroom entrance. Resident #32 stated the bathroom door had been damaged and said it had scrapes and black marks from a wheelchair, although she said her wheelchair had not made the marks and the damage was already present when she was admitted. She said the condition made her feel like staff did not care and that they had problems and did not do anything about it. The Maintenance Request Log at the nurse’s station showed only one maintenance request dated 04/01/26 and did not include requests about the bathroom door, the walls near the bathroom, or the dirty windows. Resident #32 also reported that the windows in her room were dirty on the outside. She said she had reported the windows to the Maintenance Supervisor, who told her he did not do windows, and she said she had also spoken to the Administrator, who told her it was the way the windows were made. Observation showed white coating on the upper panes and a buildup that was black, light brown, and orange on the bottom right pane of the upper portion of the window. Staff interviews confirmed they had noticed the dirty windows, did not know who was responsible for cleaning them, and had not reported them. The Maintenance Supervisor said there was no schedule for cleaning the outside windows and that he had not followed up after the resident raised the concern.
Improper use of wrist holding during resident care
Penalty
Summary
The facility failed to ensure a resident remained free from physical restraints when CNA A held the resident’s wrists during personal care on 03/16/26. The resident had diagnoses including COPD, Alzheimer’s disease, and an anxiety disorder, and her MDS showed a BIMS score of 08 with moderate cognitive impairment and a behavior of rejection of care. Her care plan did not indicate a history of resisting care or being combative with staff. Record review showed the resident’s weekly skin data form for 03/16/26 documented bruising to both forearms, while the prior week’s skin data form did not note bruising to the arms. During interviews, the resident said a CNA held her arms and turned her in bed and that the bruising occurred when staff were trying to care for her. CNA A stated the resident was combative during the brief change and that she held both wrists to keep the resident from hitting staff. CNA B stated the resident was swinging at staff, that CNA A held the resident’s wrists in the air while the brief change was completed, and that the resident was told to stop hitting. The facility’s documentation showed CNA A and CNA B both received one-on-one re-education after the incident, with instruction that if a resident refuses care or becomes combative, staff should step away and try again later or let someone else try later. The ADON and DON both stated that if a resident becomes combative during care, staff should stop and return later. The Administrator stated he was satisfied the aides were in the middle of the brief change and did the best they could to keep the resident safe, and he did not want to second guess them in that situation.
Baseline Care Plans Not Completed or Signed by RN
Penalty
Summary
The facility failed to ensure the baseline care plan was developed and implemented within 48 hours of admission for two residents, and failed to ensure a RN was part of the baseline care plan process. For Resident #71, the record showed admission to the facility with diagnoses including unspecified heart block, atypical atrial flutter, unspecified B-cell lymphoma, COPD, and type 2 diabetes. The baseline care plan dated 03/26/2026 did not address the resident’s catheter status, even though the resident was observed in bed with a catheter drainage bag attached to the bed frame and stated he had received the catheter in the hospital before admission. The baseline care plan was signed by an LVN, and there was no signature from a RN or other IDT member. For Resident #2, the record showed admission with diagnoses of anemia, atrial fibrillation, and cirrhosis, and an admission MDS reflected a BIMS score of 12 with moderate cognitive impairment. The resident required dependent assistance for bed mobility, personal hygiene, dressing, and transfer. The EHR contained no baseline care plan completed by the IDT including a RN. During interview, the resident stated she did not recall anyone visiting with her about a baseline care plan and said there was no baseline care plan meeting when she first came to the facility. Interviews with facility staff showed the MDS Coordinator stated the baseline care plan was completed by the floor nurse, social worker, department head nurses, and therapy, but not by a RN each time, and that the new EHR had nowhere for the RN to sign. The DON stated the baseline care plan should be completed by the IDT and signed by a RN, and that catheter status and other special care needs should be included. The Administrator stated the baseline care plan was an interdisciplinary form discussed with residents on admit and that it was the responsibility of the team to ensure it was completed and signed properly and a copy was provided to the resident and family. The facility policy stated the baseline care plan was to be initiated and completed within 48 hours of admission based on physician orders and nursing evaluation.
Failure to Provide Shaving as Part of Personal Hygiene Care
Penalty
Summary
The facility failed to provide the necessary services to maintain personal hygiene for Resident #44, specifically failing to ensure he was clean shaven as was his preference. Resident #44 was [AGE] years old, admitted with diagnoses including heart failure, muscle weakness, and anxiety disorder. His quarterly MDS indicated he was sometimes understood and sometimes understood others, had a BIMS score of 2 indicating severely impaired cognition, and required moderate assistance with most ADLs, including bathing and personal hygiene. Record review showed the care plan did not indicate that Resident #44 required assistance with ADLs or identify fall-related risks, although it included an intervention to provide assistance with self-care tasks as appropriate for safety. The CNA flow sheet documented bathing/hygiene assistance on 03/30/26 but did not show whether shaving was provided, and interdisciplinary progress notes did not indicate that he refused shaving. During interviews and observations, Resident #44 stated he preferred to be clean shaven and said no one offered to shave him; he had short white facial hair on repeated observations. Staff interviews confirmed CNAs were responsible for shaving residents during showers, that his shower days were Monday, Wednesday, and Friday, and that he should have been shaved as part of his routine care. The facility policy stated hair care, combing, and shaving would be provided in accordance with standard practice guidelines.
Failure to Prevent Accidents and Provide Adequate Supervision
Penalty
Summary
The facility failed to ensure that residents were free from accident hazards and did not provide adequate supervision and assistance to prevent accidents for three residents. In one incident, a male resident with severe cognitive impairment and a history of wandering and behavioral issues entered another resident's room in the memory care unit while unsupervised. He assaulted a female resident, causing multiple bruises to her face and forearm, and also struck a nurse with a plunger and a stethoscope. The incident occurred after a CNA left the unit to seek additional staff assistance, leaving the area unsupervised. The assaulted resident was found crying and distressed, with visible injuries, and required transport to the emergency room for evaluation. Documentation and interviews confirmed that the aggressive resident had not previously exhibited such behavior, but the lack of supervision allowed the incident to occur. In a separate event, another male resident with moderate cognitive impairment and a high risk for falls was left unsupervised for several hours during the night. The resident fell at midnight while attempting to walk unassisted and remained on the floor until nearly 5:00 AM before being discovered by staff. Video evidence showed that no staff checked on him during this period, despite care plans indicating he required assistance with mobility and regular checks. The resident sustained bruising and an abrasion as a result of the fall. Staff interviews revealed that the assigned CNA became overwhelmed with other resident care tasks and failed to check on the resident, while the nurse on duty did not verify the resident's status during the night. Both incidents demonstrate a failure to provide adequate supervision and assistance as required by the residents' care plans and assessments. The lack of timely staff intervention and monitoring directly resulted in resident injuries and distress. The facility's inaction in maintaining appropriate supervision and assistance for residents with known risks contributed to these deficiencies.
Failure to Ensure Safe Serving of Hot Coffee Leads to Resident Burns
Penalty
Summary
The facility failed to ensure an environment free from accident hazards, specifically regarding the serving of hot coffee, which resulted in a resident suffering second-degree burns. The resident, who had a history of chronic obstructive pulmonary disease, Parkinson's disease, and cognitive impairment, was served coffee at a temperature that was not monitored for safety. Despite being advised to wait for the coffee to cool, the resident attempted to drink it and spilled it, causing burns to her thighs and groin area. The facility did not have measures in place to prevent such incidents, as there was no policy for monitoring the temperature of hot liquids before serving them to residents. Additionally, the facility did not conduct hot liquid risk assessments for residents, which could have identified those at risk for burns from hot beverages. The dietary manager confirmed that coffee temperatures were not logged, and there was no policy requiring such logs, despite the potential risk to residents. Interviews with staff revealed a lack of awareness and training regarding the safe serving of hot beverages. The staff did not consistently use cups with lids for residents who might be at risk of spilling hot liquids. The facility's failure to implement adequate safety measures and staff training contributed to the incident, highlighting a significant oversight in ensuring resident safety from hot liquid burns.
Deficiency in Kitchen Cleaning and Maintenance
Penalty
Summary
The facility failed to maintain food service safety standards in its kitchen, as observed during a survey. Approximately six baking sheet pans were found with thick black carbon buildup on their rims, and the stove top was also covered with black carbon buildup. These conditions were noted during initial kitchen observations and subsequent rounds. Interviews with kitchen staff revealed that the cleaning of these items was not performed regularly, with one staff member admitting to cleaning the stove top only once a month. The Dietary Manager acknowledged the presence of carbon buildup and stated that deep cleaning of the stove was conducted monthly, but the kitchen was short-staffed, affecting the completion of cleaning tasks. Interviews with various staff members, including the Nutritional Aide and Maintenance Supervisor, highlighted a lack of clarity regarding responsibilities for cleaning and maintenance. The Maintenance Supervisor mentioned that the stove had been serviced months prior, but no maintenance records were available to confirm this. The Dietary Manager and other staff members expressed concerns about the potential fire hazard posed by the carbon buildup, but there was no specific policy or cleaning schedule in place to address these issues. The Corporate Regional Dietician also noted the absence of a specific policy for equipment cleaning and suggested that some pans could be replaced. A review of facility records showed that the Cooks Daily/Weekly Duties checklist required daily cleaning of ovens, but this was not consistently followed. The U.S. Food and Drug Administration Code mandates that food-contact surfaces of cooking and baking equipment be cleaned at least every 24 hours, a standard that was not met by the facility. The lack of adherence to these guidelines and the absence of proper maintenance records contributed to the deficiency in food service safety, potentially placing residents at risk of foodborne illness and contamination.
Failure to Maintain Accurate Records for Controlled Drugs
Penalty
Summary
The facility failed to establish a system for the receipt and disposition of controlled drugs, which is necessary for accurate reconciliation and maintaining drug records. During an observation and interview, it was found that the controlled medications awaiting disposal were stored in the Director of Nursing's (DON) office behind a double-locked door, with the DON being the only person with access to the keys. The DON's process involved checking the narcotic medication count with a nurse and placing the medications in a basket in the closet without logging them until the pharmacist arrived for drug destruction. This practice did not align with the facility's policy, which requires a controlled medication disposition log to be maintained for documentation purposes. The facility's policy on the disposal of medications, including controlled substances, mandates special handling, storage, disposal, and record-keeping in accordance with federal and state laws. However, the Administrator was unaware of the facility's narcotic medication policy or procedure and could not confirm if the policy was effective in preventing medication diversion. The last medication destruction was recorded on a previous date, indicating a lack of regular reconciliation and documentation of controlled substances awaiting disposal. This deficiency could potentially place residents at risk for loss of prescribed medications, compromise their safety, and lead to drug diversion.
Medication Storage and Security Deficiencies
Penalty
Summary
The facility failed to ensure that all drugs and biologicals were stored in locked compartments and under proper temperature controls, as required by State and Federal laws. This deficiency was observed in the case of a resident who had medications stored in her room without an order to self-administer. The resident, who had a BIMS score indicating intact cognition, was found with a bottle of Geri Lanta on her bedside table and later in her nightstand drawer. The resident stated that she preferred to have the medication accessible for self-administration, but acknowledged that no assessment had been completed to authorize this. Additionally, a medicine cup with an unknown white powder was found in her room, which the resident could not identify. The facility also failed to secure medication carts properly, as observed with two separate nurse's carts. On one occasion, a nurse left the Hall A cart unlocked and unattended, allowing unauthorized access. The nurse admitted to forgetting to lock the cart after retrieving an item. Similarly, another nurse left the Hall B cart unlocked while attending to a resident's blood sugar check, attributing the oversight to nervousness due to the presence of a state surveyor. Both nurses acknowledged the importance of keeping the carts locked to prevent unauthorized access and potential medication errors. Interviews with the ADON, DON, and the Administrator confirmed that the facility's policy required medication carts to be locked when unattended and medications not to be left at residents' bedsides. The staff members involved were aware of these policies but failed to adhere to them, resulting in the potential for medication errors and unauthorized access. The facility's policy emphasized that only authorized personnel should have access to medications, and all staff were trained to ensure medications were not left at bedsides.
Deficiency in Food Quality and Temperature
Penalty
Summary
The facility failed to ensure that food and drink provided to residents were palatable, attractive, and served at a safe and appetizing temperature. This deficiency was observed in four residents who were reviewed for palatable food. The residents expressed dissatisfaction with the quality and temperature of the food, with some reporting that the food was bland, cold, or not suitable for their dietary needs. The Dietary Manager and state surveyors also noted that the food sampled during a test tray was not appetizing, with issues such as bland vegetables and overly salty pureed pork chop. Resident #1, a cognitively intact female with peripheral vascular disease and muscle weakness, reported that the food was not good and portions had been cut back. Resident #57, who has Alzheimer's disease and other health conditions, stated that the food was terrible and not suitable for residents with dental issues. Resident #58, who has multiple sclerosis and paraplegia, mentioned that the quality of food had declined significantly in recent weeks. Resident #64, with essential hypertension and other diagnoses, expressed that the food was not good, particularly the supper meals. Interviews with staff members, including CNAs, LVNs, and the Dietary Manager, revealed that residents frequently complained about the food being cold, lacking taste, and not meeting their preferences. Despite the facility's efforts to offer alternative meals and accommodate residents' preferences, the complaints persisted. The facility's policy on food temperatures was not effectively implemented, as evidenced by the lack of regular test tray evaluations and the failure to address residents' concerns adequately.
Infection Control Deficiencies in LTC Facility
Penalty
Summary
The facility failed to maintain an effective infection prevention and control program, resulting in multiple deficiencies observed by surveyors. One significant issue was the failure of a Licensed Vocational Nurse (LVN) to perform proper hand hygiene during wound care for a resident. The LVN did not change gloves or sanitize hands after cleaning a wound and before applying a clean dressing, which could introduce germs into the wound. This oversight was acknowledged by the LVN, who attributed the lapse to nervousness during observation. Another deficiency involved the improper use of disinfectant in a resident's isolation room, which was supposed to be cleaned with a product effective against Clostridium difficile. The facility used a disinfectant that did not kill C. diff spores, potentially allowing the bacteria to spread. The housekeeping staff and infection preventionist were unaware of the disinfectant's ineffectiveness until informed by surveyors, highlighting a gap in the facility's infection control practices. Additional issues included staff failing to perform hand hygiene between feeding two residents, not applying enhanced barrier precautions when administering medications via gastrostomy tube or intravenous line, and not using proper personal protective equipment during tracheostomy care. These lapses in infection control practices placed residents at risk for cross-contamination and infection spread, as staff did not adhere to established protocols for hand hygiene and protective equipment use.
Failure to Properly Assess and Document Use of Restraints
Penalty
Summary
The facility failed to ensure that a resident was free from physical restraints, specifically a lap harness on a Broda chair, which was used for purposes of convenience rather than medical necessity. The resident, who was severely cognitively impaired and had multiple diagnoses including Rett's syndrome, epilepsy, and anxiety disorder, was observed multiple times with leg harnesses attached to the Broda chair. These harnesses were not documented as restraints in the resident's care plan, and there was no physician order or signed consent for their use. Interviews with facility staff, including LVNs, CNAs, the ADON, and the DON, revealed a lack of understanding and documentation regarding the use of the leg harnesses. Staff members consistently stated that the harnesses were used to prevent the resident from falling out of the chair due to her condition, but they did not consider them restraints. However, it was noted that the resident could not remove the harnesses independently, indicating that they functioned as restraints. The facility also lacked a policy on restraints, further complicating the situation. Additional documentation from the resident's MD and PASRR Habilitation Coordinator suggested that the harnesses were necessary for the resident's safety and mobility, allowing her to participate in activities and interact with her community. Despite these justifications, the lack of proper assessment, monitoring, and documentation of the harnesses as restraints constituted a deficiency in the facility's care practices.
Inaccurate MDS Assessments for Restraints
Penalty
Summary
The facility failed to ensure accurate assessments for two residents regarding the use of restraints. For Resident #2, the quarterly MDS assessment did not accurately reflect the use of a safety vest (trunk harness) or lap belt as a restraint. Despite the care plan indicating the use of these devices for positioning and safety due to the resident's profound intellectual disabilities and cerebral palsy, the MDS assessment did not list them as restraints. Observations showed Resident #2 using a trunk harness and lap belt, which restricted forward motion, but staff and medical statements indicated these devices were necessary for mobility and did not restrict freedom of movement. Similarly, for Resident #5, the quarterly MDS assessment failed to indicate the use of a limb restraint. The care plan noted the need for a lap harness for safe positioning due to the resident's Rett's Syndrome and epilepsy, but there was no order or consent for the harness. Observations confirmed the use of leg harnesses, and staff interviews revealed that the harness was used to prevent the resident from falling out of the chair. Despite this, the harness was not documented as a restraint in the MDS assessment. The facility's policy requires accurate assessments to develop a comprehensive care plan, but the inaccuracies in the MDS assessments for both residents could lead to a lack of appropriate care and services. The RAI manual defines restraints as devices that restrict movement and cannot be easily removed by the resident, which was applicable in these cases. However, the facility staff and medical professionals viewed the devices as necessary safety measures rather than restraints.
Failure to Administer Oxygen as Ordered
Penalty
Summary
The facility failed to provide respiratory care in accordance with professional standards for a resident with chronic obstructive pulmonary disease (COPD) and other health conditions. The resident, who was cognitively intact and required assistance with daily activities, had a physician's order for oxygen at 2 liters per minute via nasal cannula as needed for shortness of breath. However, observations over several days revealed that the resident was consistently receiving oxygen at 3.5 liters per minute, and at one point, the oxygen concentrator was set at 4 liters per minute. This discrepancy was not documented in the medication administration record, indicating a failure to administer oxygen as ordered. Interviews with the Licensed Vocational Nurse (LVN) and the Director of Nursing (DON) confirmed that the oxygen settings were not in compliance with the physician's orders. The LVN acknowledged that the electronic medication administration record did not prompt checks for the oxygen settings since it was prescribed on an as-needed basis. Both the DON and the facility Administrator emphasized the responsibility of nursing staff to ensure that oxygen is set at the prescribed rate. The facility's policy on applying oxygen delivery devices requires staff to verify the flow rate and document the procedure, which was not adhered to in this case.
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Illustrative
What surveyors actually found near you
We read the 40 citations issued within 25 miles in the last 12 months — and tell you exactly what happened, in plain English, matched to your record.
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.
Illustrative
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Illustrative
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Nursing homes near Carthage
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Avir At Carthage | 0.6 mi | ★★★★★ | 19 | 0 |
| Panola County Nursing & Rehabilitation | 0.9 mi | ★★★★★ | 18 | 0 |
| Heritage House Of Marshall Health & Rehabilitation | 24.1 mi | ★★★★★ | 3 | 0 |
| Garrison Nursing Home & Rehabilitation Center | 24.3 mi | ★★★★★ | 0 | 0 |
| Focused Care Of Center | 26.1 mi | ★★★★★ | 3 | 0 |
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