Methodist Sepcialty Care Center

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, staff interviews, record review and facility policy review the facility failed to develop and implement a comprehensive person-centered care plan that addressed a resident's documented and known pattern of refusing bath care for one (1) of (1) residents reviewed for care planning (Resident #27). Findings include:Record review of the facility policy Care Plans revised 2/13/25 revealed, .The plan of care should be reviewed and/or updated after each quarterly and comprehensive review as well as with any when changes in treatments and/or needs arise.4. Upon identification of a change in status the Minimum Data Set (MDS) nurse and the Interdisciplinary Team (IDT) should discuss the resident condition and collaborate on intervention options, updating/modifying the care plan as needed. a. The MDS Coordinator will determine whether a significant change in status assessment is warranted.A record review of the comprehensive care plan revealed that it did not address Resident #27's documented and…

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 record review, staff interviews, and facility policy review, the facility failed to ensure a resident's environment remained as free of accident hazards to prevent accidents for one (1) of (1) residents reviewed for falls and accident prevention. (Resident #39). Findings include:A record review of the facility policy, Fall Assessment and Prevention dated 5/14/25, reveals, .II. Procedure .Prior to turning resident, upper side rails should be fully raised and in locked position .A record review facility reported an incident (FRI) #2974987, to the Complaint Unit on 4/4/2026, titled Risk Management Accident/Incident Investigation Summary. The summary revealed that Resident #39 sustained a fall during activities of daily living (ADL) care. Upon the facility investigation and an interview with Certified Nursing Assistant (CNA)#1 involved, it was determined that one of the side rails on the left may not have been fully engaged at the time of the incident. As a result, Resident #39 fell to the floor in a supine position, sustaining a 2cm (centimeter) laceration to the scalp with…

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 observations, interviews, and record review, the facility failed to procure, store, prepare, distribute, and serve food under sanitary conditions for two (2) of four (4) survey days. Specifically, the facility failed to ensure deteriorating fruits and vegetables were removed from food storage and service areas and failed to properly clean and sanitize a food thermometer between food items during food temperature monitoring. Findings Include:A record review of the facility's policy, Food Receiving and Storage policy, effective December 2016, revealed Food shall be received and stored in a manner that complies with safe food handling practices .A record review of the facility's policy, Preventing Foodborne Illnesses Food Handling policy effective December 2016 revealed Food will be stored prepared and handled and served so that the risk of food borne illness is minimized .On 6/1/26 at 10:02 AM, observed two 1-pound boxes of strawberries in the refrigerator with received and storage dates of 5/30/2026.The strawberries were moldy and deteriorating. The Dietary Manager (DD1)…

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, record review, interview and facility policy review, the facility failed to ensure proper hand hygiene practices were performed during urinary catheter care for one (1) of (1) resident observed with an indwelling urinary catheter. Resident #12.Findings included: A record review of facility policy Handwashing/Hand Hygiene revised 12/30/24 revealed, All staff should perform proper hand hygiene procedures to prevent the spread of infection to other personnel, residents, and visitors .6. e. Before and after handling an invasive device (e.g., urinary catheters.) On 6/2/26 at 1:33 PM, Resident #12 was observed for foley catheter care provided by Certified Nursing Assistant (CNA)#4. While providing care, CNA#4 cleansed the catheter three times with wipes before removing her gloves and applying new gloves without performing hand hygiene in between. She then cleansed the penis with cleansing wipes and removed her gloves once more and applied new gloves without performing hand hygiene and cleansed…

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 that services provided met professional standards of quality related to wound care orders for one (1) of four (4) sampled residents (Resident #1). Findings include: On 10/30/25 at 10:33 AM, during a telephone interview the complainant for CI MS# 2648872 revealed she had visited Resident #1 at the facility on 10/12/25 and observed that the resident had a silver dollar sized blister on the resident's left foot. She stated that she was concerned that the wound care was not being done according to physician's orders. She reported that when she questioned the charge nurse, the nurse did was not able to provide information regarding the wound.Record review of the admission Record: revealed the facility admitted Resident #1 on 5/13/21 with diagnoses that included, and the resident had diagnoses of quadriplegia, C5-C7 complete.Record review of the Quarterly Minimum Data Set (MDS) with Assessment Reference Date (ARD) 9/24/25 for Resident #1 revealed the resident had a Brief Interview for Mental Status (BIMS)…

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, interviews, record reviews, and facility policy review, the facility failed to ensure one (1) of two (2) residents observed for incontinent care (Resident #41) received appropriate incontinence care to prevent the potential for urinary tract infections and skin breakdown. Specifically, staff failed to completely cleanse the resident during perineal care, resulting in fecal matter remaining on the resident's skin and in the perineal area. Findings Include: A review of the facility's policy titled Perineal Care, revised 05/21/25, revealed: to cleanse and dry the perineal area to promote comfort, prevent infection and skin irritation, and to emphasize good perineal hygiene. On 05/18/25 at 11:59 AM, Resident #41 was observed in bed with a tracheostomy in place. A strong odor of feces was noted in the room. On 05/19/25 at 11:36 AM, Resident #41 was observed in a wheelchair with eyes closed. A strong fecal odor remained in the room. On 05/19/25 at 1:20 PM, an observation of perineal care was conducted by Certified Nursing Assistant (CNA) #1, assisted by CNA #2. The…

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, resident and staff interviews, and facility policy review, the facility failed to secure smoking materials in a safe manner for one (1) of two (2) smokers in the facility. Resident #15 Findings Include: Review of facility policy titled Smoking Program with a revision date of 3/10/2023 revealed under, Procedure . Residents should have smoking materials labeled and locked in the medication room. Residents should not have smoking, vaping, lighters or other smoking devices or material in their possession or in their room . An observation and interview on 4/10/2024 at 9:15 AM, with Resident #15 revealed he was sitting in a motorized wheelchair in his room. A small green box that was labeled (proper name of cigarette brand) was lying on his lap. The contents of the box contained 10 cigarettes and the resident acknowledged that he had a cigarette lighter in his possession as well. An observation and interview on 4/10/2024 at 9:20 AM, with Registered Nurse (RN) #1, confirmed Resident #15 had a pack of cigarettes and a lighter in his possession, which was a fire hazard…

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 staff interviews, record review, and facility policy review, the facility failed to ensure an as-needed (PRN) psychotropic medication had a stop date for two (2) of five (5) residents reviewed for unnecessary medications. Resident #27 and Resident #33 Findings Include: Review of the facility policy titled Medication Management dated 1/2024 revealed, Based on a comprehensive assessment of a resident, the facility must ensure: . PRN (as needed) orders for psychotropic drugs are limited to 14 days. Exceptions: If the attending physician or prescribing practitioner believes that it is appropriate for the PRN (as needed) order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN (as needed) order. Resident #27 Record review of the April 2024 Physician Orders for Resident #27 revealed an order dated, 10/25/23, Xanax (antianxiety) 0.5 - 1.0 MG (milligram) tablet: Administer 0.5 - 1.0 milligram(s) by mouth PRN Q (every) 8…

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, staff interviews, record review, and facility policy review, the facility failed to prevent the possible spread of infection as evidenced by lack of a biohazard container in one (1) of three (3) residents on transmission-based precautions on initial entrance to the facility. Resident #25 Findings include: Record review of facility policy titled, Tracheostomy Care revised 4/11/24, revealed, Procedure: Remove and throw away inner cannula . i. If resident is on MDRO (multi-drug resistant organism) isolation, dispose of in biohazard bag. Record review of facility policy titled, Isolation - Categories of Transmission-Based Precautions, dated 4/1/24, revealed, .Policy Interpretation and Implementation: 1. Transmission-Based Precautions will be used whenever measures more stringent than Standard Precautions are needed to prevent or control the spread of infection. An observation and interview on 04/09/24 at 10:40 AM, revealed signage on Resident #25's door for droplet isolation. An interview with…

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.