Above average — CMS composite of the measures below.
Past the typical resurvey interval — a standard survey could occur at any time
Estimate from public CMS data, current as of June 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Bruceville Terrace - D/p Snf Of Methodist Hospital during CMS and state inspections, most recent first.
The facility did not submit the required 5-day investigation report to the state survey agency following an allegation of physical abuse in which one resident was the alleged victim and another resident was the alleged abuser. Although the initial abuse allegation was reported using the mandated reporter form and the 5-day report was prepared, it remained in a file and was never sent. In interviews, the NM, ES, and DON all confirmed that the investigative report was not forwarded within the required timeframe, contrary to facility policy that mandates prompt investigation and submission of investigation results to appropriate reporting agencies.
A resident with diabetes and end stage renal disease experienced a fall and complained of pain, but the responsible party was not notified of the incident before the resident was discharged home. Documentation showed no evidence of notification, despite facility policy requiring it, and the DON confirmed the lapse during review.
A resident with multiple serious medical conditions and moderate cognitive impairment was moved to a different room without receiving written notice or an explanation for the change. Staff confirmed that written notice is not provided for room changes, despite facility policy requiring it. The resident expressed sadness and frustration due to the lack of communication.
A resident with a language barrier and diabetes was denied her request to have a family representative present during direct care by a CNA, despite her expressed need for assistance with communication. The CNA did not consult the resident about her preference and relied solely on a communication board, leading to the resident feeling distressed and fearful during care. Staff interviews confirmed that family participation is typically allowed, but this was not honored in this case.
A resident with diabetes and intact cognition was admitted with skin excoriation on the sacral coccyx area. Despite physician orders for wound care and visible signs of partial thickness skin loss, a treatment nurse did not recognize or stage the wound as a pressure injury, incorrectly stating that only wounds with drainage qualified as skin breakdown. Review of admission photos by another nurse suggested a stage 2 pressure injury, but the DON declined to discuss wound staging, contrary to facility policy requiring accurate staging.
A nurse failed to perform hand hygiene between glove changes while providing wound care to a resident with a Stage 4 pressure injury and severely impaired cognition. The nurse also did not clean scissors before placing them with clean materials and did not perform hand hygiene after discarding used dressings, contrary to facility policy.
Two cognitively intact residents became involved in a verbal dispute over a personal item, which escalated when one resident pushed the other, causing a fall and resulting in the resident striking his head and elbow. The incident was confirmed by both residents and staff interviews, and occurred despite facility policy prohibiting abuse.
A facility failed to protect the privacy of three residents' medical records during medication administration. An LN left worksheets with identifiable health information exposed on a medication cart in the hallway. Interviews with the LN, NM, and DON confirmed this as a HIPAA violation, highlighting a breach of the facility's privacy policies.
The facility failed to prepare pureed meals according to recipes, leading to inconsistent textures and potential nutritional deficiencies. Observations showed unmeasured additions of water and thickener, resulting in overly thick and gummy pureed carrots. Interviews confirmed that recipes were not followed, risking residents' nutritional intake.
The facility failed to meet professional standards for food storage and preparation, with improperly sealed and unlabeled food items in storage, wet kitchen equipment stored improperly, and cutting boards with deep grooves. These deficiencies, observed during a kitchen tour, posed a potential risk for foodborne illness among residents.
A resident with a stage IV pressure ulcer experienced unnecessary pain during wound care because the Wound Care RN did not assess or administer pain medication beforehand. The resident's last pain medication was given the previous day, and the facility's pain management policy was not provided.
A resident's room under Enhanced Barrier Precautions had an overflowing trash bin without a lid, confirmed by the LN/IP and DON, contrary to CDC guidelines. Additionally, during wound care, the WCRN failed to perform hand hygiene, using the same gloves for multiple tasks, which was acknowledged by the WCRN and noted as against facility policy by the DON.
A resident with congestive heart failure and myocardial infarction was found to have their call light out of reach for two consecutive days, despite being dependent on staff for assistance with daily activities. Observations revealed the call light on the floor and hanging off the bed, which was confirmed by staff as not meeting expectations for accessibility.
A resident with an enterococcus infection and a coccyx pressure injury did not receive proper wound care due to a nurse's failure to perform hand hygiene between steps. The nurse acknowledged the oversight, and both the Infection Preventionist and DON confirmed the necessity of hand hygiene to prevent cross-contamination, as per CDC guidelines.
Two residents in an LTC facility experienced deficiencies in pressure ulcer care. One resident, with cerebral palsy, was not turned every two hours as required, leading to gaps in documentation and care. Another resident's low air loss mattress pump was found turned off, contrary to care plans. Staff interviews revealed a lack of awareness and documentation issues, with the DON citing a system glitch.
A resident was admitted with multiple diagnoses, including a right femur fracture, and the facility failed to conduct an initial skin assessment upon admission, delaying the identification of a Deep Tissue Pressure Injury (DTPI) on the sacrum. The assessment was completed the day after admission, contrary to the facility's policy, which required it at the time of admission.
Failure to Submit 5-Day Abuse Investigation Report to State Agency
Penalty
Summary
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 an alleged abuse incident dated 2/1/26. Admission documents showed that Resident 1 and Resident 2 were admitted in February 2026. A mandated reporter document titled "Report of Suspected Dependent Adult/Elder Abuse" dated 2/1/26 indicated that an allegation of physical abuse involving Resident 1 as the alleged victim and Resident 2 as the alleged abuser was reported to CDPH. The report established that the initial allegation was reported, but the subsequent investigative findings were not forwarded as required. During interviews, the Nursing Manager stated that the 5-day investigative report for Resident 1 and Resident 2 was not sent to CDPH. The Executive Secretary confirmed that the 5-day report for both residents had been prepared and placed in a file to be sent, but it was never actually sent, despite facility policy requiring submission of the investigation report within 5 days of the incident. The DON also confirmed that the investigative report was not sent within 5 working days. Review of the facility’s policy "Alleged/Suspected Abuse, Resident Mistreatment and Misappropriation of Resident Property" dated 2025 showed that all alleged violations were to be promptly and thoroughly investigated, with results documented, retained, and forwarded to appropriate reporting agencies, which did not occur in this case.
Failure to Notify Responsible Party of Resident Fall
Penalty
Summary
The facility failed to notify the responsible party (RP) of a resident's fall, as required by facility policy. The resident, who had diagnoses including type 2 diabetes mellitus and end stage renal disease, lost balance while returning to bed and was assisted to the floor by a CNA. The resident subsequently complained of pain in the sacrum-coccyx area. Documentation in the nursing progress notes indicated that the incident was to be followed up by the day shift nurse, but there was no evidence that the RP was informed of the fall prior to the resident's discharge home with the RP. During interviews and record reviews, the Director of Nursing confirmed that no follow-up call or notification to the RP was documented, and that the expectation was for the day shift nurse to ensure the RP was made aware of the fall. The facility's policy on falling incidents required notification of both the physician and the responsible party, but this was not carried out in this instance.
Failure to Provide Written Notice for Room Change
Penalty
Summary
The facility failed to provide written notice to a resident regarding a room change, including the reasons for the move, as required by policy. The resident, who had diagnoses of End Stage Renal Disease, septic shock, and bilateral lower extremity cellulitis, and was assessed as having moderate cognitive impairment, was moved from one room to another within the facility. The resident reported that when they refused the move, staff insisted it was mandatory and stated that no reason needed to be given. The resident did not receive any written documentation explaining the reason for the room change. Multiple staff interviews confirmed that the facility does not provide written explanations to residents when room changes occur. Review of the resident's electronic health record showed no entries documenting written notice for the room change. The facility's own policy indicated that reasonable written notice should be given for transfers within the facility, but this was not followed in this instance. The resident expressed sadness and frustration as a result of the room change and the lack of communication.
Failure to Honor Resident's Right to Family Presence and Communication During Care
Penalty
Summary
A deficiency occurred when a resident's request to have a family representative present during direct care was not acknowledged or honored by a Certified Nurse Assistant (CNA). The resident, who was admitted with Type 2 Diabetes Mellitus and had a language barrier, was assessed as cognitively intact. The care plan noted the resident spoke Spanish and had communication needs, but the communication device option was not checked. During an observation, the CNA did not allow the family representative or surveyor to observe care, despite repeated requests and the resident's language barrier. The CNA relied on gestures and a communication board for communication and did not ask the resident if she wanted her family representative present during care. The resident was observed to be visibly distressed, shaking, grimacing, and expressed fear of the CNA, stating a preference for an interpreter or family representative to be present during care. The family representative reported that the resident was now afraid to receive wound care due to inadequate communication and rough handling. Interviews with facility staff confirmed that family members are generally allowed to participate in care with the resident's permission, especially to assist with translation, but in this instance, the CNA did not follow this practice and did not consult the resident about her preferences.
Failure to Accurately Assess and Stage Pressure Injuries
Penalty
Summary
The facility failed to accurately assess and stage a resident's skin condition for pressure injuries. Upon admission, the resident, who had a history of Type 2 Diabetes Mellitus and was cognitively intact, was noted to have excoriation on the sacral coccyx area. Physician orders directed specific wound care, including cleansing, application of zinc oxide paste, and covering with a foam dressing. During wound care observation, the resident was found to have a dark red line on the coccyx, redness in the gluteal folds, skin breakdown, and peeling, which appeared consistent with partial thickness skin loss. However, the treatment nurse performing the care did not acknowledge the presence of skin breakdown or a potential pressure injury, stating that only wounds with drainage were considered skin breakdown or pressure injuries. A review of the resident's admission wound photograph by another treatment nurse indicated the wound resembled a stage 2 pressure injury upon admission. The Director of Nursing declined to answer specific questions regarding wound staging, although it was stated that all wound nurses were wound care certified. Facility policy required accurate staging of pressure injuries according to standardized guidelines, but the observed and documented actions did not align with these requirements, resulting in a failure to properly assess and stage the resident's pressure injury.
Failure to Perform Hand Hygiene During Wound Care
Penalty
Summary
The facility failed to maintain proper infection control practices during wound care for one of four sampled residents. Specifically, a treatment nurse did not perform hand hygiene between glove changes while providing wound care to a resident with a Stage 4 pressure injury in the sacral region. The nurse was observed removing the old dressing, cleansing the wound, and changing gloves multiple times without performing hand hygiene in between. Additionally, the nurse placed scissors used for dressings on a waterproof barrier pad on the resident's bed and later on a table, without cleaning them before placing them with clean materials. The nurse also did not perform hand hygiene after discarding used dressings and before continuing with other care tasks. The resident involved had severely impaired cognition, as indicated by a Brief Interview for Mental Status (BIMS) score of 0 out of 15, and was on enhanced barrier precautions. The physician's order required specific wound care procedures, including cleansing, packing, and dressing the wound. The facility's policy on hand hygiene, dated March 2024, required staff to decontaminate hands before and after patient contact, before donning gloves, before moving from a contaminated to a clean body site, and after removing gloves. Both the treatment nurse and the Director of Nursing acknowledged that hand hygiene should have been performed between glove changes, as per facility policy.
Failure to Prevent Resident-to-Resident Abuse Resulting in Injury
Penalty
Summary
The facility failed to protect a resident from abuse when one resident pushed another, resulting in a fall and injury. According to interviews and record reviews, two cognitively intact residents became involved in a verbal altercation over a personal item (a grabber). One resident accused the other of theft, leading to a confrontation in which the accused resident attempted to pass by with a walker. The accusing resident admitted to pushing the other, causing him to fall backward and strike his head and right elbow on the floor. Both residents confirmed the sequence of events during interviews, and the incident was corroborated by the facility's investigation report and staff interviews. The facility's policy prohibits abuse, mistreatment, and neglect, defining abuse as the willful infliction of injury resulting in physical harm or pain. Despite this policy, the incident occurred, and the injured resident sustained physical harm as a result of the push. Both residents were assessed as cognitively intact with no behavioral symptoms or delirium at the time of the incident, according to their Minimum Data Set assessments.
Privacy Breach During Medication Administration
Penalty
Summary
The facility failed to protect the privacy and confidentiality of three residents' personal and medical records during medication administration. The Licensed Nurse (LN) left worksheets containing identifiable health care information exposed on the medication cart in the hallway while administering medications to the residents. This occurred despite the LN covering the computer screen, indicating an oversight in ensuring all forms of protected health information were secured. The residents involved were admitted with various diagnoses, including atrial fibrillation, cellulitis, and alcohol-induced neuropathy. Interviews with the LN, Nurse Manager (NM), and Director of Nursing (DON) confirmed the breach of privacy. The LN acknowledged the oversight as a HIPAA violation, while the NM and DON emphasized the importance of covering or turning over worksheets to prevent unauthorized viewing. The facility's policies on patient rights and privacy underscore the need for confidentiality, aligning with federal HIPAA regulations. However, the actions observed during the survey did not adhere to these policies, resulting in a potential privacy breach.
Improper Preparation of Pureed Meals
Penalty
Summary
The facility failed to ensure that food was prepared in a manner that conserved nutritive value and palatability for residents on a pureed diet. During an observation in the food preparation area, a Nutrition Service Worker was seen adding an unmeasured amount of hot water to pureed carrots and sweet potatoes, resulting in a very watery texture. An attempt to correct this by adding an unmeasured volume of thickening ingredient led to an overly thick and gummy consistency. This inconsistency in food preparation was confirmed during a test meal sampling, where the pureed carrots were found to be too thick and gummy, indicating a deviation from the recipe. Interviews with the Nutrition Service Manager and Nutrition Service Director revealed that the cooks did not follow the recipes or measure ingredients accurately, which could alter the nutrition that residents receive. The Nutrition Service Director emphasized the importance of following recipes to ensure the nutritional value of the meals. This deficiency had the potential to lead to poor intake and malnutrition for residents receiving pureed meals.
Deficiencies in Food Storage and Equipment Maintenance
Penalty
Summary
The facility failed to adhere to professional standards for food storage and preparation, as observed during a kitchen tour. In the South walk-in Veg Box #2 refrigerator, several food items, including an open bag of spinach, shredded cheddar cheese, and pre-sliced Monterey cheese, were not securely sealed and lacked labels indicating the opened date and use-by date. Similarly, in the walk-in freezer, an open box of frozen cheese enchiladas was found without proper sealing. The dry food storage area contained items such as cans of diced red sweet peppers and bags of Low Sodium Country Gravy Mix without expiration or use-by date labels. These lapses in food storage practices were acknowledged by the Nutrition Service Manager (NSM) and the Nutrition Service Director (NSD), who confirmed the risk of bacterial growth and freezer burn due to improper sealing and labeling. Additionally, the facility was found to be non-compliant with standards for storing clean kitchen equipment. During the kitchen tour, stainless steel table pans and a serving container were observed with water droplets on them, indicating they were stored while still wet. The NSM and NSD both stated that kitchen equipment should be completely dry before storage to prevent bacterial growth. This practice was in violation of the US Food and Drug Administration's (FDA) 2022 Food Code, which requires equipment and utensils to be air-dried after cleaning and sanitizing. The facility also failed to maintain cutting boards in a condition that allows for effective cleaning and sanitization. Two red cutting boards used for meat and one green cutting board used for vegetables were found with deep grooves, which the NSM identified as a concern for bacterial growth. According to the FDA's 2022 Food Code, cutting surfaces that are scratched or scored should be resurfaced or discarded if they cannot be effectively cleaned and sanitized. These deficiencies in food handling and equipment maintenance posed a potential risk for foodborne illness among the 159 residents consuming facility-prepared foods.
Failure to Administer Pain Medication Before Wound Care
Penalty
Summary
The facility failed to provide appropriate pain management for a resident, identified as Resident 32, during wound care. Resident 32, who was admitted with multiple diagnoses including a stage IV pressure ulcer, was observed experiencing pain during a wound dressing change. The resident expressed that the procedure was painful and that the Wound Care Registered Nurse (WCRN) did not inquire about their pain level prior to the procedure. Further investigation revealed that the last administration of pain medication, tramadol, was given the previous day, and there was no assessment of the resident's pain needs before the wound care. The Licensed Nurse (LN 2) confirmed that the WCRN should have assessed the resident's need for pain medication 30 minutes before the procedure. The Director of Nursing (DON) stated that staff are expected to assess residents for comfort prior to care. The facility's policy on pain management was requested but not provided.
Infection Control Lapses in Resident Care
Penalty
Summary
The facility failed to maintain proper infection control practices for a resident under Enhanced Barrier Precautions. The resident's room had a trash bin overflowing with used PPE and lacked a lid, which was confirmed by the Licensed Nurse/Infection Preventionist (LN/IP) and the Director of Nursing (DON). Both acknowledged that the trash bin should have a lid to prevent the spread of infection, and the overflowing condition was unexpected. The CDC guidelines emphasize the importance of having an appropriate disposal container available in the resident's room for PPE removal. Additionally, during wound care for the same resident, the Wound Care Registered Nurse (WCRN) did not perform hand hygiene. The WCRN used the same gloves after adjusting the bedrail, positioning the resident, and removing the old wound dressing, then proceeded to handle clean wound dressing supplies without changing gloves or sanitizing hands. The WCRN admitted to the oversight, and the DON stated that staff are expected to follow hand hygiene protocols during wound care. The facility's policy on hand hygiene requires decontamination of hands after contact with a patient's skin or wound dressings.
Call Light Inaccessibility for Resident
Penalty
Summary
The facility failed to ensure that the call light was within reach for a resident, identified as Resident 143, for two consecutive days. Resident 143, who was admitted to the facility with diagnoses of congestive heart failure and myocardial infarction, was dependent on staff for assistance with bathing, toileting, dressing, bed mobility, and transfers. The resident was also incontinent and had a stage 3 pressure ulcer. During observations, the call light was found on the floor and not within the resident's reach, which was confirmed by the resident who stated a need for assistance with daily activities. On two separate occasions, the call light was observed to be inaccessible to the resident, first on the floor and then hanging off the side of the bed. Both a CNA and a licensed nurse confirmed that the expectation was for the call light to be within the resident's reach to ensure timely assistance. The deficiency was identified through observations and interviews, highlighting the facility's failure to provide a critical means for the resident to request help, thereby increasing the potential safety risk.
Infection Control Lapse During Wound Care
Penalty
Summary
The facility failed to adhere to proper infection control practices during wound care for one of the residents. The resident, who was admitted with an enterococcus infection and had a coccyx pressure injury, required specific wound care instructions. During an observation, a licensed nurse performed wound care without conducting hand hygiene between removing the old dressing, cleaning the wound, and applying a new dressing. This lapse in protocol was confirmed by the nurse, who acknowledged the importance of hand hygiene in preventing infection spread. Interviews with the Infection Preventionist and the Director of Nursing further confirmed the deficiency. The Infection Preventionist stated that hand hygiene and glove changes are necessary during wound care to prevent cross-contamination and promote healing. The Director of Nursing also confirmed that the nurse should have performed hand hygiene during the procedure. The report references CDC guidelines that emphasize the need for hand decontamination after contact with body fluids, nonintact skin, and wound dressings.
Deficiencies in Pressure Ulcer Care and Prevention
Penalty
Summary
The facility failed to provide adequate pressure ulcer care and prevention for two residents, leading to deficiencies in their treatment. Resident 1, who was admitted with encephalopathy and cerebral palsy, had an unstageable pressure ulcer on the right buttock. Despite a care plan requiring turning and repositioning every two hours, this was not implemented. Interviews with staff revealed inconsistencies in documentation and a lack of awareness about the resident's need for assistance with repositioning. The resident reported not being turned at all, which was confirmed by gaps in the documentation reviewed by the Informatics Nurse. Resident 2, admitted with a hip fracture and other conditions, also had unhealed pressure ulcers and was supposed to be on a low air loss (LAL) mattress to prevent further skin breakdown. However, during an observation, the LAL mattress pump was found turned off, contrary to the care plan. Staff interviews indicated a lack of awareness and understanding of the importance of keeping the LAL mattress operational, with the Director of Nursing attributing the issue to a system glitch. The facility's policy and procedure for LAL mattress use was not provided upon request. These deficiencies highlight a failure in implementing and documenting essential care practices for pressure ulcer prevention and treatment, as well as a lack of adherence to the facility's policies. The absence of proper documentation and staff awareness contributed to the potential risk of delayed healing and deterioration of the residents' pressure ulcers.
Failure to Conduct Timely Skin Assessment on Admission
Penalty
Summary
The facility failed to conduct an initial skin assessment upon admission for a resident, which was not completed until the day after admission. This oversight had the potential to delay the identification and treatment of a Deep Tissue Pressure Injury (DTPI) on the sacrum. The resident was admitted with a right femur fracture and other diagnoses, including protein calorie malnutrition, diabetes, and chronic kidney disease. The initial skin assessment was supposed to be performed at the time of admission, as per the facility's policy, but was delayed until the following day. Upon review, it was found that the resident's skin assessment from the acute care hospital indicated blanchable redness on the buttock, which remained unchanged. However, the DTPI on the sacrum was not documented until the day after admission. The Director of Nursing confirmed that the wound was first seen on the day after admission, and a low air loss mattress was ordered subsequently. The facility's policy required an initial skin assessment at the time of admission, which was not adhered to, leading to a delay in identifying the DTPI.
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Sacramento
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| City Creek Post Acute | 2.2 mi | ★★★★★ | 0 | 0 |
| Double Tree Post Acute Care Center | 3.7 mi | ★★★★★ | 22 | 0 |
| Bridgewood Post Acute | 3.9 mi | ★★★★★ | 3 | 0 |
| Capital Post Acute | 4.3 mi | ★★★★★ | 28 | 0 |
| Elk Grove Post Acute | 4.7 mi | ★★★★★ | 13 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release June 2026) and official state health department websites.