Bruceville Terrace - D/p Snf Of Methodist Hospital
Inspection Findings
F-Tag F0580
F 0580 Level of Harm - Minimal harm or potential for actual harm Residents Affected - Few
Immediately tell the resident, the resident's doctor, and a family member of situations (injury/decline/room, etc.) that affect the resident. **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based 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. Findings:During a review of Resident 1's facesheet (a page of the chart that contains a summary of resident's basic information), the facesheet indicated Resident 1 was admitted
on [DATE REDACTED] with diagnoses that included type 2 diabetes mellitus (DM-a disorder characterized by difficulty
in blood sugar control and poor wound healing) and end stage renal disease (ESRD-irreversible kidney failure).During a review of Resident 1's Nursing Progress Note (NPN), dated 11/23/25 at 2:51 a.m., the NPN indicated, Resident 1 had lost his balance while returning to bed, and a certified nursing assistant (CNA) assisted him to sit on the floor. At 1 a.m., Resident 1 was noted to complain of pain around the sacrum-coccyx area (lower back/tailbone area). During a review of Resident 1's NPN, dated 11/23/25 at 11:50 a.m., the NPN indicated, Resident 1 was discharged home with the RP. The NPN did not indicate that
the RP was informed of the assisted fall that had occurred.During a concurrent interview and record review
on 12/19/25 at 12:25 p.m. with Director of Nursing (DON), Resident 1's NPN on 11/23/25 at 2:51 a.m. was reviewed. The NPN indicated, .endorsed AM nurse to follow up The DON stated that calling the RP again was part of the follow-up process. Further review of the chart showed no documentation of a follow-up call to the RP. The DON confirmed that no additional follow-up call was made. The DON stated that she expected the day shift nurse to follow up and ensure the RP was made aware of the fall. The DON also stated that the nurse should have informed the RP about the fall when the RP arrived to pick up Resident 1 for discharge.During a review of the facility's policy and procedure (P&P) titled, Falling Incidents, dated 5/22/25, the P&P indicated, .notify the Physician and Responsible Party.
Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date
these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation.
LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE
TITLE
(X6) DATE
FORM CMS-2567 (02/99) Previous Versions Obsolete
Facility ID:
If continuation sheet
Event ID:
BRUCEVILLE TERRACE - D/P SNF OF METHODIST HOSPITAL in SACRAMENTO, CA inspection on recent inspection.
Found 0 violation(s). Severity: Standard violations. Status: 0 corrected, 0 pending.
Frequently Asked Questions
- What is an F-tag violation?
- F-tags are federal deficiency codes used by CMS to categorize nursing home violations. Each F-tag corresponds to a specific federal regulation (42 CFR Part 483). For example, F607 relates to abuse prevention policies, F880 relates to infection control.
- Were these violations corrected?
- Facilities must submit plans of correction and implement changes within required timeframes. CMS conducts follow-up inspections to verify corrections. Check the inspection report for specific correction dates and follow-up verification status.
- How often do nursing home inspections happen?
- CMS conducts unannounced inspections of all Medicare/Medicaid-certified nursing homes at least once per year. Additional inspections may occur based on complaints, facility-reported incidents, or follow-up to verify previous violations were corrected.
- What should families do about these violations?
- Families should: (1) Review the full inspection report for details, (2) Ask facility administration about specific corrective actions taken, (3) Check if this represents a pattern by reviewing prior inspections, (4) Compare with other facilities in SACRAMENTO, CA, (5) Report new concerns to state authorities.
- Where can I see the full inspection report?
- Complete inspection reports are available on Medicare.gov's Care Compare website (www.medicare.gov/care-compare). You can also request copies directly from BRUCEVILLE TERRACE - D/P SNF OF METHODIST HOSPITAL or from the state Department of Health. Reports include deficiency codes, facility responses, and correction timelines.