Brushy Creek Post Acute

In the surveyor’s words

From the most serious findings on record at Brushy Creek Post Acute, in the surveyor’s own words.

• Immediate jeopardy, isolatedF600Dec 23, 2025

  Based 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]. […]

• Immediate jeopardy, isolatedF678Dec 23, 2025

  Based 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. […]

• No harm, potential for more than minimal, patternF756Dec 12, 2025

  Based 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, . […]

• No harm, potential for more than minimal, patternF880Dec 12, 2025

  Based 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.Findings include:Review of the facility policy titled Enhanced Barrier Precautions dated December 2024 revealed, . Enhanced Barrier Precautions (EBPs) are utilized to prevent the spread of multi-drug-resistant organisms (MDROs) to residents . […]

• No harm, potential for more than minimal, patternF584Jun 15, 2023

  Based on observations, interviews, record review, and facility policy review, the facility failed to ensure a comfortable and homelike environment was provided for 3 (Resident (R)1, R2 and R3) of 3 sampled residents whose rooms and common areas were reviewed. Specifically, the facility failed to properly clean resident rooms and common areas and failed to follow their Homelike Environment policy. Findings include: Review of facility policy titled, Homelike Environment revised in 02/21 stated, Resident are provided with a safe, clean, comfortable and homelike environment . 2. The facility staff and management maximizes, to the extent possible, the characteristics of the facility that reflect a personalized, homelike setting. These characteristics include: a. […]