Brushy Creek Post Acute

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility neglected to provide services and care to Resident (R)1. Specifically, the facility failed to monitor and provide medications as ordered by the physician, resulting in R1 suffering a hypertensive crisis. On [DATE] at 11:30 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm. On [DATE] at 1:15 PM, the survey team provided the Administrator with a copy of the Centers for Medicare and Medicaid Services (CMS) Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.12 - Freedom from Abuse, Neglect, and Exploitation. On [DATE], the facility provided an acceptable IJ Removal Plan. [...]

Inspectors wroteBased on review of the facility policy, record review, and interviews, the facility failed to ensure that cardiopulmonary resuscitation (CPR) was initiated to Resident (R)1, Specifically, not responding in a timely manner and initiating CPR per the physician's order. On [DATE] at 11:30 AM, the State Agency (SA) determined that the facility's non-compliance with one or more federal health, safety, and/or quality regulations could cause psychosocial harm. On [DATE] at 1:15 PM, the survey team provided the Administrator with a copy of the CMS Immediate Jeopardy (IJ) Template, informing the facility IJ existed as of [DATE]. The IJ was related to 42 CFR 483.24-Quality of Life. On [DATE], the facility provided an acceptable IJ Removal Plan. On [DATE], the survey team validated the facility's corrective actions and determined the facility put forth due diligence in addressing the noncompliance. [...]

Inspectors wroteBased 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, . [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Daily Staff Posting contained the facility name, the actual hours of the nurses in each cottage, and whether or not the nurse was an RN (Registered Nurse) or LPN (Licensed Practical Nurse). This failure made visitors, families, and residents unaware of the current staffing levels in each cottage.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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.

Inspectors wroteBased 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. [...]

Inspectors wroteBased 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.

Inspectors wroteBased 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.