Deficiency Records for Bruceville Terrace - D/p Snf of Methodist Hospital
Updated as of April 01, 2024
A list of the most recent deficiencies for Bruceville Terrace - D/p Snf of Methodist Hospital. The list is based on the information provided by CMS from both standard inspections and from complaints filed by residents.
| Deficiency | Type of Deficiency | Deficiency Date | Date Corrected | Resulted from a Complaint? |
|---|---|---|---|---|
| Provide the appropriate treatment and services to a resident who displays or is diagnosed with dementia. | Health | 2023-07-05 | 2023-07-20 | Y |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-05-12 | 2023-06-12 | Y |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2023-03-24 | 2023-03-30 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2023-02-09 | 2023-03-03 | N |
| Ensure that each resident is free from the use of physical restraints, unless needed for medical treatment. | Health | 2023-02-09 | 2023-03-03 | N |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2023-02-09 | 2023-03-03 | N |
| Create and put into place a plan for meeting the resident's most immediate needs within 48 hours of being admitted | Health | 2023-02-09 | 2023-03-03 | N |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2023-02-09 | 2023-03-03 | N |
| Develop the complete care plan within 7 days of the comprehensive assessment; and prepared, reviewed, and revised by a team of health professionals. | Health | 2023-02-09 | 2023-03-03 | N |
| Post nurse staffing information every day. | Health | 2023-02-09 | 2023-03-03 | N |
| Ensure a licensed pharmacist perform a monthly drug regimen review, including the medical chart, following irregularity reporting guidelines in developed policies and procedures. | Health | 2023-02-09 | 2023-03-03 | N |
| Implement gradual dose reductions(GDR) and non-pharmacological interventions, unless contraindicated, prior to initiating or instead of continuing psychotropic medication; and PRN orders for psychotropic medications are only used when the medication is necessary and PRN use is limited. | Health | 2023-02-09 | 2023-03-03 | N |
| Ensure medication error rates are not 5 percent or greater. | Health | 2023-02-09 | 2023-03-03 | N |
| Ensure drugs and biologicals used in the facility are labeled in accordance with currently accepted professional principles; and all drugs and biologicals must be stored in locked compartments, separately locked, compartments for controlled drugs. | Health | 2023-02-09 | 2023-03-03 | N |
| Procure food from sources approved or considered satisfactory and store, prepare, distribute and serve food in accordance with professional standards. | Health | 2023-02-09 | 2023-03-03 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2023-02-09 | 2023-03-03 | N |
| Educate residents and staff on COVID-19 vaccination, offer the COVID-19 vaccine to eligible residents and staff after education, and properly document each resident and staff member's vaccination status. | Health | 2023-02-09 | 2023-03-03 | N |
| Keep all essential equipment working safely. | Health | 2023-02-09 | 2023-03-03 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2023-02-09 | 2023-03-03 | Y |
| Create arrangements with other facilities to receive patients. | Fire Safety | 2023-02-14 | 2023-02-14 | N |
| Use approved construction type or materials. | Fire Safety | 2023-02-14 | 2023-02-14 | N |
| Properly select, install, inspect, or maintain portable fire extinguishes. | Fire Safety | 2023-02-14 | 2023-02-14 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2023-02-14 | 2023-02-14 | N |
| Have generator or other power source capable of supplying service within 10 seconds. | Fire Safety | 2023-02-14 | 2023-02-14 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2023-02-14 | 2023-02-14 | N |
| Ensure proper usage of power strips and extension cords. | Fire Safety | 2023-02-14 | 2023-02-14 | N |
| Protect each resident from all types of abuse such as physical, mental, sexual abuse, physical punishment, and neglect by anybody. | Health | 2022-11-02 | 2022-12-07 | Y |
| Honor the resident's right to a dignified existence, self-determination, communication, and to exercise his or her rights. | Health | 2022-11-01 | 2022-11-15 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-11-01 | 2022-11-15 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-11-01 | 2022-11-15 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-09-22 | 2022-10-12 | Y |
| Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. | Health | 2022-09-01 | 2022-09-28 | Y |
| Develop and implement a complete care plan that meets all the resident's needs, with timetables and actions that can be measured. | Health | 2022-09-01 | 2022-09-28 | Y |
| Keep residents' personal and medical records private and confidential. | Health | 2022-08-02 | 2022-09-01 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-08-01 | 2022-09-01 | Y |
| Develop and implement policies and procedures to prevent abuse, neglect, and theft. | Health | 2022-05-31 | 2022-06-13 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2022-05-31 | 2022-06-13 | Y |
| Safeguard resident-identifiable information and/or maintain medical records on each resident that are in accordance with accepted professional standards. | Health | 2022-02-03 | 2022-05-14 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-09 | 2022-04-30 | Y |
| Not require residents to give up Medicare or Medicaid benefits, or pay privately as a condition of admission; and must tell residents what care they do not provide. | Health | 2022-02-01 | 2022-04-30 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2022-02-01 | 2022-04-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2022-02-24 | 2022-04-29 | Y |
| Post nurse staffing information every day. | Health | 2022-03-17 | 2022-04-07 | Y |
| Put firmly secured handrails on each side of hallways. | Health | 2022-03-17 | 2022-04-07 | Y |
| Have policies on smoking. | Health | 2022-03-17 | 2022-04-07 | Y |
| Provide timely notification to the resident, and if applicable to the resident representative and ombudsman, before transfer or discharge, including appeal rights. | Health | 2022-02-10 | 2022-03-25 | Y |
| Plan the resident's discharge to meet the resident's goals and needs. | Health | 2022-02-10 | 2022-03-25 | Y |
| Provide care and assistance to perform activities of daily living for any resident who is unable. | Health | 2022-02-10 | 2022-03-25 | Y |
| Ensure that a nursing home area is free from accident hazards and provides adequate supervision to prevent accidents. | Health | 2021-12-16 | 2022-02-02 | Y |
| Honor the resident's right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. | Health | 2021-12-14 | 2022-01-31 | Y |
| Provide safe, appropriate pain management for a resident who requires such services. | Health | 2021-12-08 | 2022-01-31 | Y |
| Let each resident or the resident's legal representative access or purchase copies of all the resident's records. | Health | 2021-12-21 | 2021-12-30 | Y |
| Provide enough nursing staff every day to meet the needs of every resident; and have a licensed nurse in charge on each shift. | Health | 2021-08-27 | 2021-10-11 | Y |
| Ensure that nurses and nurse aides have the appropriate competencies to care for every resident in a way that maximizes each resident's well being. | Health | 2021-06-11 | 2021-07-15 | Y |
| Respond appropriately to all alleged violations. | Health | 2021-04-20 | 2021-06-22 | Y |
| Timely report suspected abuse, neglect, or theft and report the results of the investigation to proper authorities. | Health | 2021-05-19 | 2021-06-03 | Y |
| Provide family notifications of emergency plan. | Fire Safety | 2019-08-21 | 2019-09-10 | N |
| Have a complete alarm system manually initiated and initiated by fire sprinkler system connection. | Fire Safety | 2019-08-21 | 2019-09-10 | N |
| Have approved installation, maintenance and testing program for fire alarm systems. | Fire Safety | 2019-08-21 | 2019-09-10 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2019-08-21 | 2019-09-10 | N |
| Install corridor and hallway doors that block smoke. | Fire Safety | 2019-08-21 | 2019-09-10 | N |
| Meet requirements for the installation and maintenance of electrical systems. | Fire Safety | 2019-08-21 | 2019-09-10 | N |
| Meet requirements for the use of electrical equipment. | Fire Safety | 2019-08-21 | 2019-09-10 | N |
| Have proper medical gas storage and administration areas. | Fire Safety | 2019-08-21 | 2019-09-10 | N |
| Honor the resident's right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. | Health | 2019-07-18 | 2019-08-12 | N |
| Ensure each resident receives an accurate assessment. | Health | 2019-07-18 | 2019-08-12 | N |
| Provide appropriate treatment and care according to orders, resident?s preferences and goals. | Health | 2019-07-18 | 2019-08-12 | N |
| Ensure menus must meet the nutritional needs of residents, be prepared in advance, be followed, be updated, be reviewed by dietician, and meet the needs of the resident. | Health | 2019-07-18 | 2019-08-12 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2019-07-18 | 2019-08-12 | N |
| Provide and implement an infection prevention and control program. | Health | 2019-07-18 | 2019-08-12 | N |
| Develop and implement policies and procedures for flu and pneumonia vaccinations. | Health | 2019-07-18 | 2019-08-12 | N |
| Develop a communication plan. | Fire Safety | 2018-08-15 | 2018-09-04 | N |
| Keep aisles, corridors, and exits free of obstruction in case of emergency. | Fire Safety | 2018-08-15 | 2018-09-04 | N |
| Inspect, test, and maintain automatic sprinkler systems. | Fire Safety | 2018-08-15 | 2018-09-04 | N |
| Ensure that personnel concerned with handling of medical gases and cylinders are trained on the risk. | Fire Safety | 2018-08-15 | 2018-09-04 | N |
| Provide safe, appropriate dialysis care/services for a resident who requires such services. | Health | 2018-07-12 | 2018-08-06 | N |
| Try different approaches before using a bed rail. If a bed rail is needed, the facility must (1) assess a resident for safety risk; (2) review these risks and benefits with the resident/representative; (3) get informed consent; and (4) Correctly install and maintain the bed rail. | Health | 2018-07-12 | 2018-08-06 | N |
| Conduct and document a facility-wide assessment to determine what resources are necessary to care for residents competently during both day-to-day operations and emergencies. | Health | 2018-07-12 | 2018-08-06 | N |
| Provide and implement an infection prevention and control program. | Health | 2018-07-12 | 2018-08-06 | N |
