Bruceville Terrace - D/P SNF Of Methodist Hospital

During observation, interview, and record review, the facility failed to ensure one of four sampled residents (Resident 1) was treated with respect and dignity when Resident 1's request to have family present during direct care was not acknowledged by Certified Nurse Assistant 1 (CNA 1). This failure had the potential for Resident 1 to not to receive care based on her needs and preferences. A review of Resident 1's clinical record indicated Resident 1 was admitted in Middle 2025 with diagnosis of Type 2 Diabetes Mellitus (a condition where your body either doesn't make enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/22/25 indicated Resident 1 had a Brief Interview for Mental Status (BIMS, tests cognition) score of 13 out of 15 indicating Resident 1 was cognitively intact. A review of Resident 1's care plan, titled .Alteration in Communication r/t [sic, related to] language barrier. dated 7/16/25, indicated, . Language(s) spoken: Spanish . The box next…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to accurately assess one of four sampled residents (Resident 1's) skin for stageable pressure injuries (damage to the skin and underlying tissues caused by prolonged pressure on the body). This failure had the potential to result in worsening of Resident 1's skin breakdown.A review of Resident 1's clinical record indicated Resident 1 was admitted in Middle 2025 with diagnoses which included Type 2 Diabetes Mellitus (a condition where your body either doesn't make enough insulin or can't properly use the insulin it produces, leading to high blood sugar levels). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool) dated 7/22/25, indicated Resident 1 had a Brief Interview for Mental Status (BIMS, tests cognition) score of 13 out of 15 indicating Resident 1 was cognitively intact. During a review of Resident 1's initial skin assessment dated [DATE], the skin assessment indicated excoriation (skin damage) on sacral coccyx…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure infection control practices were maintained during wound care for one of four sampled residents (Resident 2) when licensed staff did not perform hand hygiene between changing gloves when performing wound care. This failure had the potential to result in cross contamination of the wound and spread of infection for Resident 2. A review of Resident 2's clinical record indicated resident 2 was admitted in July 2025 with diagnoses which included pressure injury (pressure sore, ulcer, or bedsore) of sacral (a triangular bone at the base of the spine) region. During a review of Resident 2's Minimum Data Set (MDS, an assessment tool) dated 5/27/25 indicated Resident 2 had a Brief Interview for Mental Status (BIMS, tests cognition) score of 0 out of 15 indicating Resident 2 had severely impaired cognition. During a review of Resident 2's clinical record, the physician treatment order dated 7/11/25 indicated, . Pressure injury Stage 4 [severe, deep wound that extends through the skin, fat, and muscle,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to ensure one of three sampled residents (Resident 1) was free from abuse when he was pushed by Resident 2. This failure resulted in Resident 1 falling backward and striking the back of his head and right elbow on the floor. Findings: During a review of Resident 2's admission Minimum Data Set (MDS- a federally mandated resident assessment tool), dated 5/1/25, indicated Resident 2's Brief Interview for Mental Status (BIMS- a brief screening that aids in detecting cognitive impairment) score was 14 which indicated he was cognitively intact and as having no delirium or behavioral symptoms. Review of the facility's investigation report indicated Resident 2 was interviewed by the facility's Medical Social Worker (MSW) on 7/3/25. The investigation report indicated, According to the patient (Resident 2), an argument began because he believed his roommate had taken his grabber, which the roommate denies. The patient (Resident 2) acknowledged that, while his…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to protect the privacy and confidentiality for 3 of 48 sampled residents (Resident 133, Resident 141, and Resident 314) when the Licensed Nurse (LN) left worksheets containing residents' identifiable health care information exposed to view during medication administration. This failure had the potential to result in Resident 133, Resident 141, and Resident 314's confidential information to be viewed by unauthorized staff, residents, and visitors. Findings: A review of Resident 133's Facesheet indicated Resident 133 was admitted to the facility in June 2024 with diagnoses including atrial fibrillation (irregular and very rapid heart rhythm) and cellulitis (skin infection). A review of Resident 141's Facesheet indicated Resident 141 was admitted to the facility in October 2024 with a diagnosis of alcohol induced neuropathy (chronic alcohol abuse damages the nerves leading to sensory and motor dysfunction). A review of Resident 314's Facesheet indicated Resident 314 was admitted to the facility in February 2025…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure food was prepared in a manner to conserve nutritive value and palatability for residents receiving a pureed diet when the pureed carrots were prepared without using a recipe. This failure had the potential of leading to poor intake and malnutrition for the residents receiving pureed meals. Findings: During a concurrent observation, interview, and recipe review on 2/25/25 at 9:45 a.m., in the food preparation area, with the Nutrition Service Worker 1-Cook (NSW 1-C), Lead [NAME] for the day, and Nutrition Service Worker 2- Trainee [NAME] (NSW 2-TC) 2), NSW 1-C was showing the puree recipes and discussed the options used for adjusting the texture of pureed dishes. NSW 1-C had stated using water is seldom used as well as thickener ingredients. NSW 2-TC was observed liberally pouring an unmeasured amount of hot water into both the carrot puree and sweet potato puree. Observed NSW 1-C attempting to remedy the very watery and runny textured purees by adding an unmeasured volume of puree thickening ingredient.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to provide food storage and preparation in accordance with professional standards for food service safety when: 1. Food items in refrigerator, freezer, and dry food storage had food items that were not securely closed, did not have expiration date labels, or no label with opened date and use by date labels; 2. Clean stainless steel table pans were found stacked and stored wet on storage shelves; and 3. Two red cutting boards for meat and 1 green cutting board for vegetables had deep grooves. Theses failures had the potential of leading to food borne illness for 159 residents who are eating facility prepared foods. Findings: 1. During the initial kitchen tour on 2/24/2025, at 9 a.m., with the Nutrition Service Manager (NSM), the following was observed: The South walk-in Veg Box #2 refrigerator contained an open bag of spinach that had cellophane loosely wrapped around the spinach bag. An opened bag of shredded cheddar cheese with cellophane…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one of three sampled residents (Resident 32) was administered pain medication before providing wound care. This failure resulted in Resident 32 having unnecessary pain during wound care. Findings: Resident 32 was admitted to the facility in mid-2024 with diagnoses which included stroke, hypertension (uncontrolled blood pressure), dementia (memory loss) and a stage IV pressure ulcer (full thickness skin and tissue loss with exposed muscle, tendon, ligament, cartilage, or bone). A review of Resident 32's most recent Minimum Data Set (MDS - a federally mandated resident assessment tool) dated 12/29/24, indicated Resident 32's memory was severely impaired. During an observation on 2/27/25 at 8:41 a.m., in Resident 32's room, Resident 32 wound dressing change was being provided by the Wound Care Registered Nurse (WCRN). Resident 32 stated, this is painful. During an interview on 2/27/25 at 8:42 a.m., with Resident 32, Resident 32 stated, She [WCRN] never asked about pain. Yes, I have pain, this does not…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure infection control practices were maintained for one (Resident 32) of 48 sampled Residents when: 1. Resident 32's room, with Enhanced Barrier Precautions (wearing gowns and gloves during close-contact care activities with residents with open wounds or medical devices to stop the spread of tough-to-treat infections), trash bin did not have a lid and was overflowing with used Personal Protective Equipment (PPE - items, such as gowns and gloves, worn to minimize exposure that can cause serious illnesses and healthcare workers wear to prevent contact with infectious agents or body fluids), and 2. Wound Care RN (WCRN) did not perform hand hygiene during Resident 32's wound care. These failures had the potential to spread harmful germs to patients, leading to increased risk of infections, including those resistant to antibiotics (medicines to treat bacterial infections), and potentially causing serious illness to Resident 32. Findings: 1. During a concurrent observation and interview on 2/27/25 at 10:55 a.m.,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

3/1Based on observation, interview, and record review, the facility failed to ensure the call light was within reach for 1 of 48 sampled residents (Resident 143) for 2 consecutive days, This failure decreased the potential for the residents to get assistance from staff in a timely manner when needed and increased potential safety risk. Findings: Resident 143 was admitted to facility in 2025 with a diagnosis of congestive heart failure (a heart disorder which causes the heart to not pump the blood efficiently) and Myocardial Infarction (a heart attack -heart muscle begins to die due to lack of sufficient blood supply and oxygen). The admission Minimum Data Set (MDS-a standardized evaluation tool used to assess health and functional status of a resident) indicated Resident 143 was dependent with bathing, toileting, dressing, bed mobility and transfers. The MDS indicated Resident 143 was incontinent with bowel and bladder functions and had a stage 3 pressure ulcer (full-thickness loss of skin wound). The MDS assessment triggered care plan risk areas for care providers to monitor…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow proper infection control practices for one (Resident 1) of four sampled residents when staff did not perform hand hygiene (the process of washing or sanitizing one's hands to prevent the spread of disease) during wound care for Resident 1. This failure had the potential to impede the wound healing process for Resident 1. Findings: Resident 1 was admitted to the facility in May of 2024 with diagnoses that included enterococcus (a type of bacteria) infection. During a review of Resident 1's Ordering Information ([NAME]), with the start date of 7/3/24, the [NAME] indicated, Special Instructions: Coccyx pressure injury [damage to the skin and the underlying tissue caused by constant pressure or friction]-cleanse with wound cleanser. apply (sic) foam dressing daily. During a concurrent observation and interview on 10/10/24 at 10:40 a.m., with Licensed Nurse 1 (LN 1), LN 1 performed wound care for Resident 1. LN 1 removed Resident 1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure pressure injury prevention and treatment consistent with the professional standards of practice were promoted for two of three sampled residents (Resident 1 and Resident 2) when: 1. Resident 1's care plan for turning and repositioning every two hours was not implemented; and 2. Resident 2's low air loss (LAL) mattress (specialty bed designed to distribute the patient's body weight over a surface to prevent skin breakdown) bed pump was turned off. These failures had the potential risk to result in delayed healing and deterioration of the pressure ulcers (PUs). Findings: 1. Resident 1 was admitted to the facility in the middle of 2024 with diagnoses which included encephalopathy (a brain condition that causes a rapid decline in brain function), and cerebral palsy (group of disorders that affect a person's ability to move and maintain balance and posture). During a review of Resident 1's Minimum Data Set (MDS, an assessment tool),…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, record and policy review, the facility failed to follow their policy and procedure to conduct an initial skin assessment upon admission for one of four sampled residents (Resident 1) when Resident 1's admission skin assessment was not completed until the day after admission. This failure had the potential for a DTPI (Deep Tissue Pressure Injury- an injury that occurs when pressure damages the soft tissue beneath the skin surface, but there is no open wound) on the sacrum (base of the spine) to not be identified upon admission causing a delay in intervention and treatment. Findings: A review of Resident 1's admission History LTC [Long Term Care], dated 4/2/24, indicated Resident 1 was admitted to the facility on [DATE] at 6:30 p.m. for right femur fracture [broken thigh bone] with surgical repair and had other multiple diagnoses including protein calorie malnutrition (deficiency of protein and other nutrients), diabetes (too much sugar in the blood), and chronic kidney disease (loss of kidney…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review the facility failed to ensure the medication error rate did not exceed 5% (five percent) for one of 38 sampled residents (Resident 68). When a Licensed Nurse (LN) administered Resident 68's medications which included: 1. Insulin lispro (medication used to lower blood sugar level) not in accordance with Physician Orders. 2. Polyethylene glycol 3350 (medication used for constipation) not in accordance with Physician Orders. As a result, two errors were identified out of 30 opportunities for error during the observation of medication administration resulted in facility's medication error rate being 6.67%. Findings: 1. During an observation of medication administration on 2/5/24 at 8:08 a.m., LN 4 was observed to prepare Resident 68's medications including 11 units of insulin lispro. On 2/5/24 at 8:22 a.m., LN 4 administered 11 units of insulin lispro and there was no breakfast tray for Resident 68. During an interview on 2/5/24 at 8:30 a.m. with LN 4, LN 4 stated, Breakfast was served between 7 to 7:30 a.m. and Resident 68's breakfast…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure medications were stored and secured correctly, when: 1. An expired menthol tube (a medication used for wound treatment) was found in the medication room B. 2. Eleven expired acetaminophen suppositories (medication to be inserted in rectum for fever and pain) were found in medication room C inside the medication refrigerator. 3. An incineration/sharps bin (a box with one way locking mechanism for discarding used needles) was not secured/locked to the medication cart 1 at station A. It contained pharmaceutical products being accessible to residents or unauthorized individuals. These failures had the potential for medication ineffectiveness, medication diversion, and medication misuse. Findings: 1. During a concurrent inspection and interview on [DATE] at 8:52 a.m. with Registered Nurse (RN) 3 in the medication rooms B, a tube of menthol 1% (one percent - a medication for wound treatment use) was found in a tray with expiration date…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record record, the facility failed to store food in accordance with professional standards for food service safety when canned food was found in the dry storage area without a received date or use-by date. This failure had the potential to result in food borne illness. Findings: During a concurrent observation of the dry storage area and interview on 2/7/24 at 9:05 a.m. with the Nutrition Services Manager (NSM), the NSM verified six 6 lb (lb: pound, a unit of measurement) 9 oz (oz: ounce, a unit of measurement) cans of beets, six 6 lb 15 oz cans of chickpeas, six 6 lb 8 oz cans of mixed vegetables, and six 6 lb 10 oz cans of pineapple chunks had only a manufacturer's date, and no received or use by date. NSM was asked his expectations for the labeling of canned foods and stated, It should have a received date and a use by date. During an interview on 2/7/24 at 10:52 a.m. in the kitchen office with Registered Dietician (RD), RD was asked her expectations for the labeling of canned goods and stated, We follow standard operating procedures with food…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to follow infection control guidelines to provide a safe, sanitary, and comfortable environment for census of 164 residents when: 1. Restorative Nurses Assistant 1 (RNA) touched Resident 5's roll/bread with bare hands, 2. RNA 2 did not sanitize hands before touching Resident 46's eating utensils, 3. Uncovered and partially covered green linen carts contained clean linens, 4. Laundry worker's uniform (LW) touched the clean white linen while transporting it. 5. Peripherally inserted central catheter (PICC, long thin flexible tube inserted through a vein) dressing was not changed for Resident 458 and Resident 469, 6. Resident 465's isolation trash can was overflowing and without a cover, 7. Urinals were unlabeled for Resident, Resident 114, Resident 52, and Resident 103, 8. Resident 50 and Resident 93's respiratory equipment were unlabeled, 9. Resident 29's wheelchair and Resident 14's geri chair (a lounge chair) arm rest pads were in disrepair…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure resident needs were accommodated when one of 38 sampled resident's (Resident 41) low air loss mattress (LAL, designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was off and the resident had a Stage 4 (full thickness tissue loss with exposed bone, tendon, or muscle) pressure ulcer. This failure had the potential for the pressure ulcer to worsen and for the resident not to reach her highest practicable well-being. Findings: Resident 41 was admitted to the facility in the winter of 2019 with diagnoses which included multiple sclerosis (a nervous system disease that affects the brain and spinal cord). During a review of Resident 41's Physician Order (PO), dated 5/3/17, the PO indicated, Specialty Bed Type: Low Air Loss .Special Instructions: For wound healing. During a review of Resident 41's History and Physical (H&P), dated 8/28/23, the H&P indicated, .bed bound .pressure ulcer of sacral region, stage 4 . During a review of Resident 41's Minimum Data…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure the communication needs were met for one of 38 sampled residents (Resident 151) when there was no communication sheet or device accessible for the staff to communicate with the resident. This failure had the potential for Resident 151 to have unmet care needs. Findings: Resident 151 was admitted early 2024 with diagnoses which included end stage renal disease and dialysis (ESRD, kidney failure that required procedure to removes excess waste producs from the blood). During a review of Resident 151's Minimum Data Set (MDS, an assessment tool), dated 1/17/24, the MDS indicated moderate memory loss. During a review of Resident 151's care plan (CP) titled, Communication, dated 1/17/23, the CP indicated, Alteration in communication r/t [related to] language barrier .Language(s) spoken: Telugu .Resident will: Be able to communicate his/her basic needs utilizing the communication devices provided .Communication Board Provided . During a concurrent observation and interview on 2/12/24 at 9:20 a.m. with Resident…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure a safe and a secure environment were provided to four of 38 sampled residents (Resident 10, Resident 44, Resident 87 and Resident 133) when the floor was found to be in disrepair. This failure had the potential to result in accidents and injuries. Findings: Resident 10 was admitted to the facility in mid-2023 with diagnoses which included glaucoma (eye condition that causes blindness), hypertension (blood pressure that is higher than normal) and asthma (difficult to breathe with inflamed airways). During a review of Resident 10's restorative nursing care plan, dated 3/24, the care plan indicated, .walks with a front wheel walker short distance. Resident 44 was admitted to the facility in late 2013 with diagnoses which included transient ischemic attack (TIA, brief stroke causing weakness), hemiplegia or hemiparesis (weakness on one side of the body), and osteoporosis (bone loss). During a review of Resident 44's restorative nursing care plan, dated 1/24, the nursing care plan indicated, .ambulation…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure pharmacy services were maintained for one of 38 sampled residents when Resident 125 was not able to receive pain medication patch according to the Physician's Order. This failure had the potential for Resident 125 to have unwanted adverse effects or inadequate pain relief from the medication patch. Findings: During an observation on 2/5/24 at 8:40 a.m. in Resident 125's room, Licensed Nurse (LN) 5 was observed to provide a lidocaine transdermal patch (a medication patch to relief localized pain) to Resident 125. Resident refused to get the patch since an older patch was still in place on the right lower leg (RLL) which was applied previously with no documentation. During an interview on 2/5/24 at 8:45 a.m. with LN 5, LN 5 stated, Resident 125 showers during the evening shift after 3 p.m. and the old patch will be removed along with ACE wrap (a bandage) prior to shower. During an interview on 2/5/24 at 2:22 p.m. with LN 5, LN 5 stated that lidocaine patch had been rescheduled for 3 p.m. to be removed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, facility failed to ensure that one of 38 sampled residents (Resident 49) was free of an unnecessary psychotropic medications (drug prescribed to affect the mind, emotions, or behavior) when Resident 49 was receiving quetiapine, an antipsychotic medication, indicated for bipolar disorder (a mental illness causes shift in mood, energy, activity levels, and concentration) for an inadequate indication and dosage while Resident 49 was not a physical threat to self or others. This failure resulted in Resident 49 being extremely sleepy, tired, and weak during morning hours and declining to participate in the morning care, treatment, and activities. Findings: During a concurrent interview and record review on 2/7/24 at 8:34 a.m. with the facility's Pharmacist (PHARM), the PHARM stated, Resident 49 was admitted to the facility from the acute care hospital in April of 2022, with diagnoses including bipolar disorder, hypertension [a condition when pressure of blood is too…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure one of 38 sampled residents (Resident 68), was free from significant medication errors when Resident 68's insulin lispro (medication used to lower blood sugar level) was administered after breakfast and not in accordance with the Physician's Order. This failure resulted in Resident 68 experiencing lightheadedness and having abnormally low blood sugar levels that needed immediate medical interventions. Findings: During an observation of medication administration on 2/5/24 at 8:22 a.m., Licensed Nurse (LN) 4 was observed to administer Resident 68's medications which included 11 units of insulin lispro. During an interview on 2/5/24 at 8:30 a.m. with LN 4, LN 4 stated, Breakfast was served between 7 to 7:30 a.m. and Resident 68's breakfast tray was already removed from the room. Reconciliation of the observation of medication administration with Resident 68's current Physician Orders indicated, Insulin lispro [Brand name of insulin] 100 u/ml [units/milliliter, unit of measure] give 8 [eight] units,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.