Bruceville Terrace - D/P SNF of Methodist Hospital

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure one of two sampled residents (Resident 1) was free from abuse, when Resident 2 hit Resident 1 multiple times. This failure had the potential to negatively impact Resident 1's highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared, stored, served, or distributed in accordance with professional standards of food serve safety when:Staff did not clean two ice machines located in the hospital's main kitchen and the skilled nursing facility. Staff did not maintain several pieces of cookware in usable condition. Staff left opened packaged and prepared food items in the walk in refrigerator and dry storage area without required labels and dates. The metal coating of the can opener blade was worn off. Dietary staff did not follow proper refrigerator thawing procedures that allowed identification of when food was pulled from the freezer and when it should be used. Two cooks used masks instead of proper beard restraints and did not fully cover facial hair. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive, person centered care plan for two of 35 sampled residents (Resident 163 and 106), when:The facility placed Resident 163 on Enhanced Barrier Precautions (EBP- an infection control intervention used to reduce transmission of multidrug resistant organisms through targeted gown and glove use) and not initiate a care plan. Resident 106's care plan for EBP and for the use of Peripherally Inserted Central Catheter (PICC line- a long, flexible tube inserted into a large vein, typically in the upper arm, and threaded to a central vein above the heart, and is used for long-term intravenous treatments such as antibiotics) were not developed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure biologicals were stored in accordance with the facility's policies and procedures (P&P), and accepted professional principles for a census of 163 when 11 packets of expired food thickeners (specialized powders or gels that instantly increase the viscosity of hot or cold liquids and foods primarily designed to achieve safe, consistent textures for individuals with difficulty swallowing) were found stored in D station medication cart 1. This failure created the potential for residents to receive biologicals that were expired or with unsafe or reduced potency which could have caused unwanted effects to the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow and maintain an effective infection prevention and control program for a census of 163 when;1. A facility staff did not wear required personal protective equipment (PPE) when accessing and using the Peripherally Inserted Central Catheter (PICC line- a type of central line which is inserted into a large vein, typically in the upper arm, and threaded to a central vein above the heart, and is used for long-term intravenous treatments such as antibiotics) of Resident 130 who was on enhanced barrier precaution (EBP- also known as enhanced standard precaution/ESP, infection control intervention designed to reduce transmission of multidrug-resistant organisms [MDROs- bacteria that resist treatment with more than one antibiotic] that employs targeted gown and glove use);2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that staff delivered intravenous (IV) therapy (administration of fluids or medications into the vein) was consistent with standards of practice and the facility's policy and procedures (P&P) for one out of 35 sampled residents (Resident 106) when Resident 106's Peripherally Inserted Central Catheter (PICC line- a long, flexible tube inserted into a large vein, typically in the upper arm, and threaded to a vein above the heart, and is used for long-term intravenous treatments such as antibiotics) hub (the external plastic junction connecting the catheter to extension tubes) was not scrubbed with antiseptic pad before use. This failure created the potential for unsafe IV therapy delivery, possible infection, and prevented Resident 106 from achieving the highest practicable well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure safe medication administration practices were followed when the facility's medication error rate was more than 5% (percentage- number or ratio that expressed as a fraction of 100) for a resident census of 163. Medication administration observations were conducted over multiple days, at varied times, in random locations throughout the facility. The facility had a total of two errors out of 30 opportunities which resulted in a facility wide medication error rate of 6.67% in one out of 9 residents (Resident 125) observed for medication administration. These failures had the potential for unsafe and ineffective medication therapy of Resident 125 and had the potential to negatively affect the residents' medical conditions.

Inspectors wroteBased on interview and record review the facility failed to report the results of an abuse investigation to the state survey agency (California Department of Public Health, CDPH) within 5 working days of the incident (allegation of abuse dated 2/1/26). This failure resulted in CDPH being unaware of the outcome of the abuse investigation, and had the potential for the abuse investigation to not be investigated thoroughly. A review of the facility's admission documents indicated Resident 1 and Resident 2 were admitted in February 2026. During a review of document titled Report of Suspected Dependent Adult/Elder Abuse (a California mandated reporter document used to report suspected abuse or neglect of seniors (65+) or dependent adults (18-64 with disabilities)) dated 2/1/26, indicated an allegation of abuse was reported to CDPH. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify one of three sampled residents' (Resident 1) Responsible Party (RP) of Resident 1's fall in the facility. This deficient practice resulted in RP 1 being unaware of Resident 1's fall and actual condition that may impact RP 1's ability to ensure appropriate care and support following discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed for one of four sampled residents (Resident 1) to be notified of room change, when the facility did not provide written notice for room change including reasons for the room change for Resident 1. This failure resulted in Resident 1 not receiving a written explanation of why the move was required, resulting in Resident 1 expressing sadness and frustration.

Inspectors wroteDuring 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). [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wrote3/1Based 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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).

Inspectors wroteBased 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.

Inspectors wroteBased 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%.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.