BRIARCLIFF HEALTH CENTER

Nursing Home Inspector

3403 S VINE AVE
TYLER, TX 75701
Smith County
Phone: 903-581-5714
Provider Number: 675142
Last Inspection: 07/28/2017

About the Nursing Home

Number of Beds: 230
Number of Residents: 173
Beds Available: 57
Percent Occupancy: 75%
Insurance Accepted: Medicare & Medicaid
Types of Councils: Resident
Ownership: For profit - Partnership
Within Hospital?: NO

About State Inspection Deficiencies

Nursing Homes that are Medicare and/or Medicaid certified are licensed by the state and are required to comply with rigid standards enforced by regular facility inspections and extensive evaluations.

The state inspection deficiencies provided here are accounts reported by state inspectors of every discrepancy found where the home failed to meet the minimum standards set forth by state and federal regulations. If a home does not show any deficiencies, it has met the minimum standards required.

Please note: Findings in these inspections do not present a complete picture of the quality of care provided. Information in this database should be interpreted carefully and used in conjunction with other sources, as well as a visit to the nursing home.


Deficiency Ratings

Our nursing home inspector tool compares the severity of deficiences rather than the number of deficiences. We calculate the severity of each deficiency using the formula:

Severity Rating = Scope + Level of Harm.

Deficiency Rating= Sum of ALL Severity Ratings

Severity Scope Level of Harm
2 1-Isolated 1-Potential for minimal harm
3 2-Pattern 1-Potential for minimal harm
3 1-Isolated 2-Minimal harm or potential for actual harm
4 3-Widespread 1-Potential for minimal harm
4 2-Pattern 2-Minimal harm or potential for actual harm
4 1-Isolated 3-Actual harm
5 3-Widespread 2-Minimal harm or potential for actual harm
5 2-Pattern 3-Actual harm
5 1-Isolated 4-Immediate jeopardy to resident health or safety
6 3-Widespread 3-Actual harm
6 2-Pattern 4-Immediate jeopardy to resident health or safety
7 3-Widespread 4-Immediate jeopardy to resident health or safety

Deficiency Ratings
By Region

Lower Numbers Are Better

 

36

Facility
30

County
22

TX
20

USA

Deficiency Ratings
By Year

Lower Numbers Are Better

 

36

2017
40

2016
32

2015

Medicare Ratings

Overall Rating: Overall Rating
Health Rating: Health Rating
Staff Rating: Staff Rating
Quality Rating: Quality Rating

 

Details by Inspection Date

7/28/2017 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Allow residents to self-administer drugs if determined safe. Pattern : Minimal 4 9/7/2017
 
Failed To: Provide medically-related social services to help each resident achieve the highest possible quality of life. Pattern : Minimal 4 9/7/2017
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 9/7/2017
 
Failed To: Keep the rate of medication errors (wrong drug, wrong dose, wrong time) to less than 5%. Pattern : Minimal 4 9/7/2017
 
Failed To: Provide routine and emergency drugs through a licensed pharmacist and only under the general supervision of a licensed nurse. Widespread : Minimal 5 9/7/2017
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 9/7/2017
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 9/7/2017
 
Failed To: Keep all essential equipment working safely. Widespread : Minimal 5 9/7/2017
 

7/28/2016 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Let residents refuse treatment, refuse to take part in an experiment, or formulate advance directives. Pattern : Minimal 4 9/10/2016
 
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Pattern : Minimal 4 9/10/2016
 
Failed To: Ensure each resident receives an accurate assessment by a qualified health professional. Pattern : Minimal 4 9/10/2016
 
Failed To: Provide care by qualified persons according to each resident's written plan of care. Pattern : Minimal 4 9/10/2016
 
Failed To: Ensure that residents with limited range of motion receive appropriate treatment and services to increase range of motion or prevent further decrease in range of motion. Pattern : Minimal 4 9/10/2016
 
Failed To: Prepare food that is nutritional, appetizing, tasty, attractive, well-cooked, and at the right temperature. Widespread : Minimal 5 9/10/2016
 
Failed To: Store, cook, and serve food in a safe and clean way. Widespread : Minimal 5 9/10/2016
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Widespread : Minimal 5 9/10/2016
 
Failed To: Keep accurate, complete and organized clinical records on each resident that meet professional standards. Widespread : Minimal 5 9/10/2016
 

7/22/2015 Inspection

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Keep residents' personal and medical records private and confidential. Isolated : Minimal 3 9/4/2015
 
Failed To: Provide residents with private access to a telephone. Widespread : Minimal 5 9/4/2015
 
Failed To: Provide resident groups or resident family groups with private space to meet. Pattern : Minimal 4 9/4/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Pattern : Minimal 4 9/4/2015
 
Failed To: Make sure menus meet the resident's nutritional needs and that there is a prepared menu by which nutritious meals have been planned for the resident and followed. Pattern : Minimal 4 9/4/2015
 
Failed To: Have a program that investigates, controls and keeps infection from spreading. Pattern : Minimal 4 9/4/2015
 
Failed To: Make sure that the nursing home area is safe, easy to use, clean and comfortable for residents, staff and the public. Pattern : Minimal 4 9/4/2015
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Pattern : Minimal 4 9/4/2015
 

Complaint Investigation Deficiencies

These deficiencies resulted from complaints investigated by the state inspectors and substantiated.

4/28/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. Widespread : Immediate 7 5/26/2015
 
Failed To: Provide necessary care and services to maintain or improve the highest well being of each resident . Widespread : Immediate 7 5/26/2015
 

4/15/2015 Investigation

 
Deficiency Description Scope : Level of Harm 1 -- Rating -- 7 Corrected
Failed To: Have a program that investigates, controls and keeps infection from spreading. Isolated : Minimal 3 5/15/2015
 
Failed To: Make sure that nurse aides show they have the skills and techniques to be able to care for residents' needs. Isolated : Minimal 3 5/15/2015
 

About The Staff

(Higher Numbers Are Better)

Staffing Hours Per Day Per Resident... This Facility County Avg TX State Avg
Number of Residents 173 82.27 75.11
Registered Nurses 0.53 0.49 0.59
Licensed Practical / Vocational Nurses 0.95 0.86 0.94
Certified Nursing Assistants 2.37 2.24 2.20
Total Staff Hours 3.85 3.59 3.73

 


About the Residents

(Lower Numbers Are Better)

Percent of Residents... This Facility% County Avg% TX State Avg%
of high risk long-stay residents with pressure ulcers 6 6 6
of long-stay residents assessed and appropriately given the pneumococcal vaccine 93 88 91
of long-stay residents assessed and appropriately given the seasonal influenza vaccine 97 91 92
of long-stay residents experiencing one or more falls with major injury 6 3 3
of long-stay residents who have depressive symptoms 4 3 3
of long-stay residents who lose too much weight 6 6 5
of long-stay residents who received an antianxiety or hypnotic medication 27 27 26
of long-stay residents who received an antipsychotic medication 19 15 17
of long-stay residents who self-report moderate to severe pain 3 7 5
of long-stay residents who were physically restrained 0 0 0
of long-stay residents whose ability to move independently worsened 6 19 20
of long-stay residents whose need for help with daily activities has increased 26 18 18
of long-stay residents with a catheter inserted and left in their bladder 1 1 2
of long-stay residents with a urinary tract infection 6 2 3
of low risk long-stay residents who lose control of their bowels or bladder 38 42 49
of short-stay residents assessed and appropriately given the pneumococcal vaccine 75 81 77
of short-stay residents who had an outpatient emergency department visit 13 14 13
of short-stay residents who made improvements in function 67 61 59
of short-stay residents who newly received an antipsychotic medication 3 2 2
of short-stay residents who self-report moderate to severe pain 6 15 12
of short-stay residents who were assessed and appropriately given the seasonal influenza vaccine 76 72 74
of short-stay residents who were rehospitalized after a nursing home admission 25 23 23
of short-stay residents who were successfully discharged to the community 51 46 46
of short-stay residents with pressure ulcers that are new or worsened 1 0 0