Inspection Reports for
McCrite Plaza at Briarcliff Skilled Facility

The complaint involved a missing card and narcotic count sheet for oxycodone for Resident #1. The medication was signed for by LPN A but was missing on 10/28/25. An investigation included interviews, review of camera footage, and drug testing of involved staff. The medication was replaced and staff were re-educated. LPN A was suspended pending investigation and returned to work after education.

The facility failed to follow policy by not securing Resident #1's controlled substance, oxycodone, leading to its loss. An investigation was conducted, corrective actions were implemented including replacement of medication and staff education, and the issue was corrected by 11/5/2025.

The complaint investigation found that Resident #1 was given Resident #2's medications in error, resulting in actual harm. The error was discovered after several doses were administered over a weekend. The facility's system for double-checking new admission medications failed due to workload and staffing issues. The resident was hospitalized and remains stable but will not return until blood pressure normalizes.

The facility failed to ensure Resident #1 received treatment and quality care according to professional standards when Licensed Practical Nurse (LPN) A transcribed Resident #2's medications into Resident #1's Medication Administration Record, resulting in Resident #1 receiving 42 doses of the wrong medications and subsequent hospital admission for low blood pressure and increased heart rate. The facility's medication administration and double-check systems failed, especially over the weekend when audits were not performed.

The complaint investigation found that CPR was performed on Resident #1 who had a signed DNR order. Staff did not check the DNR book or electronic medical record promptly, and no DNR signage was present on the resident's door. The resident's Nurse Practitioner confirmed that CPR should not have been performed and staff should have followed the resident's wishes.

The facility failed to honor the DNR order for Resident #1 and performed Cardiopulmonary Resuscitation (CPR) despite the resident's documented wishes. The deficiency affected one of four sampled residents and was classified as minimal harm with few residents affected.

The facility was found deficient in multiple areas including failure to ensure proper documentation and honoring of advance directives, maintaining a clean and safe environment, completing criminal background checks timely, recognizing and reporting significant weight changes, providing adequate assistance with activities of daily living, safe transfer techniques, proper respiratory care, medication administration, food safety, and ensuring accessible call light systems.

The facility failed to provide a safe and comfortable home-like environment as the heating system could not maintain adequate temperatures, resulting in resident rooms as low as 58 degrees. Portable heat pumps were used as a temporary measure, and one resident was temporarily relocated. The Administrator was unaware that portable heaters were prohibited in long-term care facilities and did not consult the Engineering & Consultation Unit.

The facility had multiple deficiencies including failure to properly manage resident funds, maintain a clean and safe environment, provide adequate personal care and grooming, ensure safe mechanical lift transfers, respond timely to call lights, maintain food safety practices, implement a water management plan to prevent Legionella, and maintain adequate ventilation in bathrooms.

The visit was complaint-related, focusing on allegations that staff did not use proper techniques during mechanical lift transfers, potentially causing accidents or injuries. The complaint was substantiated based on observations and interviews.

The facility failed to ensure staff used proper techniques to reduce the possibility of accidents or injuries when transferring four of 12 sampled residents using a mechanical lift. Staff inconsistently followed manufacturer guidelines regarding the positioning of lift legs and locking/unlocking of rear casters during transfers.

The facility was found deficient in multiple areas including failure to honor residents' dignity with timely call light response causing incontinence, incomplete care plans, medication administration errors, inadequate catheter and respiratory care, insufficient staffing leading to extended call light response times, improper medication storage and labeling, food safety violations, and lapses in infection prevention practices.