Briarcliff Skilled Nursing Facility

Penalties

• Nov 5, 2025 — Fine ($15,733)
• Jan 30, 2025 — Fine ($135,980)

Inspection findings

1. Apr 1, 2026 Health · 8 findings
   • Not serious Scope/severity D

     F0553 Resident Rights Deficiencies

     Allow resident to participate in the development and implementation of his or her person-centered plan of care.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0584 Resident Rights Deficiencies

     Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0655 Resident Assessment and Care Planning Deficiencies

     Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity E

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity D

     F0677 Quality of Life and Care Deficiencies

     Provide care and assistance to perform activities of daily living for any resident who is unable.

     Corrected Apr 17, 2026 · CMS health inspection

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Apr 17, 2026 · CMS fire safety

   • Not serious Scope/severity E

     K0374 Smoke Deficiencies

     Install smoke barrier doors that can resist smoke for at least 20 minutes.

     Corrected Apr 17, 2026 · CMS fire safety

2. Nov 5, 2025 Health · 1 finding
   • Serious Scope/severity K Complaint

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     CMS health inspection

3. Jan 30, 2025 Health · 12 findings
   • Not serious Scope/severity D

     F0604 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment.

     Corrected Feb 1, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Feb 1, 2025 · CMS health inspection

   • Serious Scope/severity J

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Feb 5, 2025 · CMS health inspection

   • Not serious Scope/severity D

     F0695 Quality of Life and Care Deficiencies

     Provide safe and appropriate respiratory care for a resident when needed.

     Corrected Feb 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Feb 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0761 Pharmacy Service Deficiencies

     Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs.

     Corrected Feb 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0804 Nutrition and Dietary Deficiencies

     Ensure food and drink is palatable, attractive, and at a safe and appetizing temperature.

     Corrected Feb 1, 2025 · CMS health inspection

   • Not serious Scope/severity F

     F0812 Nutrition and Dietary Deficiencies

     Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards.

     Corrected Feb 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Feb 1, 2025 · CMS health inspection

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Feb 7, 2025 · CMS fire safety

   • Not serious Scope/severity E

     K0511 Services Deficiencies

     Have properly installed electrical wiring and gas equipment.

     Corrected Feb 7, 2025 · CMS fire safety

   • Not serious Scope/severity D

     K0929 Gas, Vacuum, and Electrical Systems Deficiencies

     Ensure precautions for handling oxygen cylinders and equipment are correctly followed.

     Corrected Feb 7, 2025 · CMS fire safety

4. Dec 13, 2023 Health · 12 findings
   • Not serious Scope/severity D

     F0641 Resident Assessment and Care Planning Deficiencies

     Ensure each resident receives an accurate assessment.

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0645 Resident Assessment and Care Planning Deficiencies

     PASARR screening for Mental disorders or Intellectual Disabilities

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0656 Resident Assessment and Care Planning Deficiencies

     Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured.

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0689 Quality of Life and Care Deficiencies

     Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents.

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0692 Quality of Life and Care Deficiencies

     Provide enough food/fluids to maintain a resident's health.

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0758 Pharmacy Service Deficiencies

     Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited.

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity E

     F0759 Pharmacy Service Deficiencies

     Ensure medication error rates are not 5 percent or greater.

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0880 Infection Control Deficiencies

     Provide and implement an infection prevention and control program.

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     F0908 Environmental Deficiencies

     Keep all essential equipment working safely.

     Corrected Dec 20, 2023 · CMS health inspection

   • Not serious Scope/severity D

     K0321 Smoke Deficiencies

     Ensure that special areas are constructed so that walls can resist fire for one hour or have an approved fire extinguishing system.

     Corrected Feb 29, 2024 · CMS fire safety

   • Not serious Scope/severity E

     K0372 Smoke Deficiencies

     Ensure smoke barriers are constructed to a 1 hour fire resistance rating.

     Corrected Feb 29, 2024 · CMS fire safety

5. Nov 13, 2023 Health · 2 findings
   • Not serious Scope/severity D Complaint

     F0607 Freedom from Abuse, Neglect, and Exploitation Deficiencies

     Develop and implement policies and procedures to prevent abuse, neglect, and theft.

     Corrected Dec 9, 2023 · CMS health inspection

   • Not serious Scope/severity D Complaint

     F0755 Pharmacy Service Deficiencies

     Provide pharmaceutical services to meet the needs of each resident and employ or obtain the services of a licensed pharmacist.

     Corrected Dec 9, 2023 · CMS health inspection

Owners and managers (as published by CMS)

• BEQUETTE, AARON — adp of the snf, NOT APPLICABLE, since 03/06/2024
• BEQUETTE, AARON — operational/managerial control, NOT APPLICABLE, since 03/06/2024
• CAMPBELL, SCOTT — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/08/2025
• CHANCE, JAMES — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/08/2025
• FISHER, JAMES — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/08/2025
• GOVATHOTI, DEEPTI — adp of the snf, NOT APPLICABLE, since 05/31/2014
• LANGDON, THOMAS — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/08/2025
• MCGEHEE, WILLIAM — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/08/2025
• MILLER, RANDI — adp of the snf, NOT APPLICABLE, since 06/06/2022
• STRATTON, CHARLES — corporate officer, NOT APPLICABLE, since 05/01/2005
• TAYLOR, JOHN — individual is an owner, partner or trustee of any adp of the snf, NOT APPLICABLE, since 12/08/2025
• LIBERTY COUNTY HOSPITAL DISTRICT NO 1 — 5% or greater direct ownership interest, 100%, since 03/31/2017
• LIFETIME WELLNESS, LTD. — adp of the snf, NOT APPLICABLE, since 09/23/2021
• MARTUS FINANCIAL SERVICES, INC. — adp of the snf, NOT APPLICABLE, since 12/31/2023
• PF CARTHAGE SNF OPS, LLC — operational/managerial control, NOT APPLICABLE, since 09/23/2021
• PF CARTHAGE SNF OPS, LLC — adp of the snf, NOT APPLICABLE, since 12/08/2025
• PHARMERICA DRUG SYSTEMS LLC — adp of the snf, NOT APPLICABLE, since 08/27/2017
• PRESERVATION FREEHOLD COMPANY — adp of the snf, NOT APPLICABLE, since 09/23/2021
• REHAB PRO LP — adp of the snf, NOT APPLICABLE, since 09/23/2021
• SANCTUARY LTC, LLC — adp of the snf, NOT APPLICABLE, since 09/23/2021
• STONEGATE SENIOR LIVING, LP — operational/managerial control, NOT APPLICABLE, since 06/22/2022
• STONEGATE SENIOR LIVING, LP — adp of the snf, NOT APPLICABLE, since 12/08/2025
• UMB BANK NATIONAL ASSOCIATION — 5% or greater mortgage interest, NOT APPLICABLE, since 09/23/2021