Brushy Creek Post Acute

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, record review, and facility policy review, the facility failed to ensure residents were free from unnecessary psychotropic medications for 3 (Residents (R)10, R51, and R127) of 6 residents reviewed for unnecessary medications in a total sample of 31. The facility failed to ensure adequate monitoring had occurred for R10's use of an antipsychotic medication. In addition, the facility failed to ensure psychotropic medications had a stop date in excess of 14 days. These failures placed the residents at risk of having unmet care needs and a decreased quality of life.Findings Include:Review of the facility policy titled, Psychotropic Medication Use, dated February 2025 revealed, . Residents do not receive psychotropic medications that are not clinically indicated and necessary to treat a specific condition documented in the medical record .When determining whether to initiate, modify, or discontinue medication therapy the interdisciplinary team conducts and documents and evaluation of…

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 observations, interviews, record review, and facility policy review, the facility failed to administer medications in a manner to prevent cross-contamination for 1 (Resident (R)36) and to implement Enhanced Barrier Precautions (EBP) for 2 residents (R115 and R105) in a total sample of 31. These failures placed the residents at risk for cross-contamination and/or worsening health concerns.Findings include:Review of the facility policy titled Enhanced Barrier Precautions dated December 2024 revealed, . Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents . Indwelling medical devices include central lines, urinary catheters, feeding tubes, and tracheotomies .Examples of secretions or excretions include wound drainage, fecal incontinence or diarrhea, or other discharged from the body that cannot be contained and pose an increased potential for extensive environmental contamination and risk transmission of a pathogen .Review of 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and facility policy review, the facility failed to assess the ability to manage and self-administer medications in 1 out of 5 residents, (Resident (R)13), reviewed for unnecessary medications out of a total sample of 31 residents. This failure increased the risk of medication errors for R13.Findings include:The facility's Self-Administration of Medications policy, with a revision date of February 2021, states, Residents have the right to self-administer medications if the interdisciplinary team has determined that it is clinically appropriate and safe for the resident to do so. The policy also confirms that the (MAR) should indicate if a dose is self-administered. Review of a Progress Note dated 05/25/23 in the electronic medical record (EMR) revealed R13 was admitted to the facility on [DATE], following a hospitalization for a left leg fracture and respiratory failure. The EMR Orders also revealed that the resident had a tracheostomy with no ventilator 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, record review, interviews, and document review, the facility failed to provide physician-ordered adaptive equipment for 1 resident, (Resident (R)16), out of the sample of 31 residents. The facility's failure to provide the adaptive utensils increased the risk that R16 would lose his independence in eating. Findings include:The facility provided a form titled Best Practice: Adaptive Feeding Equipment dated 12/20/23. Per the document, the process for getting adaptive equipment included a therapy referral, followed by an order if necessary. The nursing department confirmed the order and communicated it to the dietary department and appropriate nursing staff and updated the care plan. Once notified, the dietary department updated the tray card. A review of R16's Face Sheet, found under the Census tab of the electronic medical record (EMR), revealed the resident was admitted to the facility on [DATE], with diagnoses including but not limited to: encephalopathy (brain dysfunction), dysphagia…

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 observations, interviews, record review, and policy review, the facility failed to ensure that two Residents(R)93, and R107) of two residents sampled for restraints, were free from restraints. Specifically, R93 and R107 were observed seated in Broda chairs with chair alarms on, and with bed alarms situated on both of these beds. Additionally, there was no documentation that less restrictive methods were attempted. Continued use of the position alarms has the potential to cause a decline in physical functioning, including an increased dependance in activities of daily living (e.g., ability to walk), impaired muscle strength and balance, decline in range of motion, and risk for development of contractures. Findings include: Review of the facility's policy titled Restraint Policy dated 04/21, revealed, Policy Statement .restraints shall only be used to treat the resident's medical symptom(s) and never for discipline or staff convenience, or for the prevention of falls .Physical restraints are defined as…

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 record review, interview, and document review, the facility failed to revise the Preadmission Screening and Resident Review (PASARR) Level I for one of three residents (Resident (R) 34) reviewed for PASARR out of a sample of 29 residents when there was a new diagnosis of mental illness. This had the potential for a failure to identify what specialized or rehabilitative services the resident needed and whether placement in the facility was appropriate. Findings include: Review of R34's Profile tab of the electronic medical record (EMR) revealed she was admitted to the facility on [DATE] with diagnoses which included major depressive disorder, single episode, and generalized anxiety disorder. A new diagnosis of schizoaffective disorder was added on 09/01/23. Review of R34's PASARR Level 1 Screening Form, with review date of 03/25/24 and located in the Misc tab of the EMR, revealed mental illness diagnoses of anxiety and depression. Psychotropic medications listed included quetiapine 25 milligrams (mg) 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews, record review, and policy review the facility failed to ensure for one Resident(R)295) of six residents sampled for accidents, maintained a safe, hazard free environment. Specifically, staff left a wooden chair next to the resident's bed and R295 supposedly hit her head on the arm of the chair, resulting in a laceration to her forehead that required sutures. Failure to ensure that residents have a safe and hazardous free environment could result in further accidents with injuries. Findings include: Review of R295's undated admission Record located in the electronic medical record (EMR), under the Profile tab indicated the resident was admitted to the facility on [DATE], with diagnoses including Alzheimer's disease, difficulty in walking, and muscle weakness. Review of R295's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/25/24 and the Brief Interview of Mental Status (BIMS) score was three out of 15, indicating the resident was severely cognitively impaired…

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 interviews, record review, and policy reviews the facility failed to ensure that one Resident(R)93 of five residents sampled for unnecessary medications was monitored for behaviors, side effects and efficacy of an antipsychotic medication. The failure to monitor for adverse effects and efficacy does not ensure the safe administration and dosing of the resident's antipsychotic medications. Findings include: Review of the facility's policy titled Antipsychotic Medication Use dated 07/22 indicated, staff will observe, document, and report to the attending physician information regarding the effectiveness of any interventions, including antipsychotic medications. Nursing staff shall monitor for and report any of the following side effects and adverse consequences of antipsychotic medications to the attending physician: general/anticholinergic: constipation, blurred vision, dry mouth urinary retention, sedation. Cardiovascular: orthostatic hypotension, arrhythmias. Metabolic: increase in total cholesterol…

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 review of facility policy, record review, interview, and observation, the facility failed to report, to the state agency, an allegation of sexual abuse involving Resident (R)1's and R2's, for 2 of 2 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Report and Investigation last revised in August 2022, revealed, All reports of resident abuse . are reported to local, state, and federal agencies . Findings of all investigations are documented and reported. 1. c. Resident to resident altercations-Sexual Contact- Required to report immediately but no later than 2 hours- . Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown. Review of R1's Face Sheet revealed R1 was admitted to the facility on [DATE], with diagnoses including but not limited to: encephalopathy, hypertension, Type 2 Diabetes Mellitus, GERD, anxiety disorder, suicidal ideation, depression, and Dementia 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on review of facility policy, record review, interview, and observation, the facility failed to report, to the state agency, an allegation of sexual abuse involving Resident (R)1's and R2's, for 2 of 2 residents reviewed for abuse. Findings include: Review of the facility policy titled, Abuse, Neglect, Exploitation or Misappropriation- Report and Investigation last revised in August 2022, revealed, Findings of all investigations are documented and reported. 1. c. Resident to resident altercations-Sexual Contact- Required to report immediately but no later than 2 hours- . Sexual activity or fondling where one of the resident's capacity to consent to sexual activity is unknown. Investigating Allegations 1. All allegations are thoroughly investigated. The administrator initiates investigations . 7. The individual conducting the investigation as a minimum: a. Reviews the documentation and evidence. b. Reviews the resident's medical record to determine the resident's physical and cognitive status at the time of…

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 policy review, record review, and interview, the facility failed to ensure 4 of 4 residents and/or their representatives (Resident (R) 13, R32, R114, and R134) reviewed for an emergent discharge to the hospital out of a total sample of 30 were provided with a written notice transfer notice that included all required information. The facility's transfer notice forms did not include information on how to appeal, if desired. In addition, although transfer forms prepared by the facility were provided to Emergency Medical Services (EMS) and the hospital where the resident was being transferred, the facility failed to assure that both the resident and their representative also received the forms. This failure has the potential to affect the resident and/or their Resident Representative (RR) in not having the knowledge of where and why a resident was transferred, and/or how to appeal the transfer, if desired. Findings include: Review of the facility policy titled Transfer or Discharge, Emergency, revised…

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 review, and review of facility policy, the facility failed to ensure 4 of 4residents (Resident (R) 13, R32, R114, and R134) reviewed for hospitalization and/or their Resident Representative (RR) received a written bed hold notice upon emergent transfer to the hospital. This failure had the potential to contribute to possible denial of re-admission following a hospitalization for residents transferred emergently to the hospital. Findings include: 1. Review of R13's admission Record from the electronic medical record (EMR) revealed a facility admission date of 03/29/21. Review of a SNF/NF [Skilled Nursing Facility/Nursing Facility] to Hospital Transfer Form, dated 06/07/22, revealed R13 was being sent to the hospital. Review of the EMR Census Tab revealed R13 was on Hospital Leave effective 06/08/22. Further review of the EMR revealed no evidence of the provision of a written bed hold notice to either the resident or RR at the time of this transfer. In response to a request for evidence…

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 review, and review of the Resident Assessment Instrument (RAI) manual used as facility policy, the facility failed to ensure the Minimum Data Set (MDS) assessment for one of 30 sampled residents (Resident (R) 113) was accurate. R113's MDS was not accurately coded to indicate the resident was receiving dialysis services related to end stage renal disease. The failure to accurately code/assess the resident's condition has the potential to affect the care planning for the resident to receive all required services. Findings include: Review of R113's admission Record from the electronic medical record (EMR) revealed the resident was admitted on [DATE] with medical diagnoses that included end stage renal disease. Review of R113's EMR Orders tab showed a physician order for Dialysis Center: . Days of treatment: MWF [Monday, Wednesday, Friday] . Chair time: 6am . The order was revised on 08/29/22 with a start date of 08/31/22. Review of dialysis communication forms and progress notes in 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.