Accel at College Station

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 4 residents reviewed for discharge planning. 1. The facility failed to inform Resident #1's FM about his discharge to another facility on 06/04/2026. 2. The facility failed to inform the Ombudsman of Resident #1's discharge on [DATE] to another facility. This failure could place residents at risk of not receiving care and services to meet their needs at discharge to the other facility due to the receiving facility not getting Resident #1's medications, and diet orders.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents remained free of any significant errors for one of four residents (Resident #1) reviewed for medications and pharmacy services. The facility failed to ensure the physician's orders were followed for Resident #1 when MA A administered 3 different medications that could affect the heart when the orders stated to hold the medications for heart rate/pulse less than 60 and Resident #1's heart rate was documented to be less than 60 on 06/19/2026 and 06/20/2026. This failure could place residents at risk of not receiving the intended therapeutic benefits of the medication and symptomatic changes in vital signs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for two of eight (Resident #2 and Resident #3) residents reviewed for reasonable accommodation of needs. The facility failed to ensure RN B was not on her cell phone while sitting at the dining room table with Resident #2 and Resident #3 during breakfast on 07/08/2026. This failure had the potential to place all residents at risk of not having their needs met timely and decreased dignity.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 5 (200-hall nurse cart) medication carts reviewed for drug storage and labeling. The facility failed to ensure the 200-hall nurse cart was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure weekly skin assessments were accurately documented for 1 of 8 (Resident #1) residents reviewed for skin assessments. The facility failed to ensure LVN D provided accurate documentation of skin assessments when she documented a skin assessment on Resident #1 on 06/23/2026. Resident #1 was discharged to the hospital on [DATE], had not returned and was not in the facility on 06/23/2026. This failure could place residents at risk of worsening skin issues, infection, and not receiving appropriate care.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person -centered care plan, and the residents' choice for one (Resident #1) of 5 residents reviewed for quality of care. The facility failed to promptly identify and intervene for an acute change in Resident #1's condition related to congestive heart failure (CHF), resulting in the family calling 911 to transport the resident to the hospital. The resident was admitted to the hospital with respiratory distress and pulmonary edema. An Immediate Jeopardy (IJ) was identified on 01/28/2026. The IJ template was provided to the facility on [DATE] at 12:16 PM. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 5 residents (Resident #1 observed for resident rights. The facility failed to ensure Resident #1 was treated with respect when Resident #1's personal cell phone was placed on the bedside rolling table, where she could not reach it, by ADON A when she was talking to her son while she was in respiratory distress. This failure could place residents at risk lack of advocacy and frustration.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a comprehensive care plan was reviewed and revised by theinterdisciplinary team after each assessment for 1 of 5 (Resident #2) reviewed for care plans. The facility failed to ensure Resident #2's care plan was revised to reflect Resident #2 was on Enhanced Barrier Precautions . This failure could place residents at risk of not receiving appropriate care to meet their needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection for 1 of 4 residents ( Resident #2) reviewed for infection control. 1. The facility failed, on 01/14/2026, to ensure RN C sanitized her hands prior to donning gloves while providing colostomy care to Resident #2.2. The facility failed, on 01/14/2026, to ensure RN C wore PPE (gown) while providing high contact resident care ( colostomy care) to Resident #2. These failures could place residents at risk for infection and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living (ADLs) received necessary services to maintain personal hygiene for one (Resident #1) of seven residents reviewed for ADLs, in that: The facility failed to provide showers to Resident #1 in compliance with her shower schedule. This deficient practice could place residents at risk of a decline in hygiene, at risk of skin breakdown, level of satisfaction with life, and feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free from unnecessary drugs for one resident (Resident #1) of seven reviewed in that: The facility failed to follow Resident #1's Nephrologist's orders on 11/13/2025 to discontinue medications metformin, potassium citrate, prenatal vitamin, valsartan-hydrochlorothiazide. This failure affected Resident #1 and could have affected all residents receiving medication by placing them at risk of illness, toxicity, or other adverse reactions.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident had a right to a dignified existence for 1 (Resident #1) of 6 residents reviewed for resident rights. The facility failed to ensure that Resident #1 did not lie sideways on his bed and was covered in dried feces and a full brief on 08/30/25. This failure could place residents at risk of an undignified existence and not receiving care.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preference of each resident, an ongoing program to support residents in their choice of activities designed to meet the interests of and support the physical, mental, and psychosocial well-being for 2 of 5. (Residents #65 and Resident #67) reviewed for activities residents reviewed for activities. A-The facility failed to ensure daily activities occurred on a regular basis for residents who were bed fast . B-The facility failed to ensure Room visits were conducted and met the needs of the residents. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Aide wore a beard guard when standing over clean dishes on food prep table. 2. The facility failed to ensure Dietary [NAME] changed her gloves during food preparation after touching contaminated bread plastic bag. This failure could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to ensure that the resident has the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers for 1 (Residents #35) of 5 residents reviewed for resident rights. The facility failed to obtain an Antipsychotic or Neuroleptic Medication Treatment informed consent (form 3713 Medication Consent Form) for the use of Risperdal (an antipsychotic medication used for major depressive disorder) for Resident #35. The failure could place residents at risk of receiving medications without prior consent and without the option to choose alternative treatment or decline based on awareness of risk and benefits of the medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 5 residents (Residents #64) reviewed for advanced directives, in that: Resident #64's OOH-DNR (Out of Hospital-Do Not Resuscitate) form was not available in her medical records and failed to ensure they had a completed OOH-DNR prior to obtaining a Physician's order for DNR for Resident #64. This failure could place residents at risk for not having their end of life wishes honored.

Inspectors wroteBased on interview and record review, the facility failed to assess each resident quarterly (every 3 months) using the MDS form specified by the state and approved by CMS for 1 of 5 residents (Resident #7) reviewed for assessments. The facility failed to ensure Residents #7's quarterly MDS assessment was completed within 3 months from the previous assessment. This failure could place residents at risk of not receiving necessary care or receiving inappropriate care for their conditions.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all Pre-admission Screening and Resident Review (PASARR) Level I screenings were completed accurately and that a PASARR Level II assessment was provided for 1 (Resident #68) of 2 residents reviewed who had a mental illness. Resident #68's PASARR Level I did not identify a mental illness diagnosis that was present at admission. This failure had the potential to place all residents with a mental illness at risk of not receiving necessary assessments, care, and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility did not provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biological) to meet the needs of each resident for one (Resident # 8) of five residents reviewed for pharmaceutical services. The facility failed to ensure MA A completed the medication administration for Resident #8 when she left the medications in a cup at his bedside and left prior to Resident #8 taking the medication. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation and interview the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 3 medication carts reviewed for storage of drugs and biologicals. The facility failed to prevent Medication Cart #1 being unattended and unlocked near the five hundred hall nurses' desks on 05/20/2025. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications, missing medication, and access of others to residents' medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 4 residents (Resident #28) reviewed for infection control. MA A failed to properly sanitize or wash hands prior to the beginning of medication preparation for Resident #28 during an observation of medication pass on 05/20/2025. This failure places residents at risk for infection by the spreading of germs that could lead to illness and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one (Resident #1) of ten residents reviewed for care plans. The facility failed to ensure staff followed Resident #1's care plan on 03/26/25 when CNA A was giving her a bed bath alone and she slid from the bed onto the floor sustaining a severe laceration to her right hip and fracture to her left hip. An IJ was identified on 04/09/25. The IJ template was provided to the facility on [DATE] at 5:36 pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards as is possible and ensure each resident received adequate supervision for one (Resident #1) of six residents reviewed for accidents and hazards, in that: The facility failed to protect Resident #1, who required a two person assist for toilet, transfers, bed mobility and bathing, when CNA A, acting alone on 03/26/2025, assisted Resident #1 with ADL care. Resident #1 slid off her bed, sustained a severe laceration (a tear or cut in the skin or other tissues caused by trauma) to her right hip and a fracture to her left hip. An IJ was identified on 04/09/25. The IJ template was provided to the facility on [DATE] at 5:36 pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluid were administered consistent with professional standards of practice in accordance with physician orders, the comprehensive-centered care plan, and the resident's goals and preferences for two (Resident #1 and Resident #2) of two residents reviewed for parenteral fluids. 1. The facility failed to ensure Resident #1's PICC line dressing was changed every 7 days or as needed as Resident #1 went 27 days without a dressing change. Resident #1's dressing was dated 2/20/2025 and was not changed on 02/27/2025, 03/06/2025, and 03/13/2025. 2. The facility failed to ensure Resident #1, and Resident #2 were on enhanced barrier precautions for PICC lines. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 03/18/2025 at 2:25 PM and an IJ template was provided. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure the resident was free from neglect for one resident (Resident #1) of four residents reviewed for neglect. The nursing staff failed to assess or make any observations on Resident #1 after he was admitted to the facility 01/14/2025 at 5:47 PM until approximately 7:45 PM. Resident #1 was unable to assist self to the bathroom and urinated on himself and was in distress. This failure placed residents at risk of neglect, injury, and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient preparation and orientation to resident to ensure safe and orderly transfer or discharge from the facility for one of three (Resident #2) residents reviewed for discharges. The facility failed to provide and document that Resident #2 was given an orientation prior to discharging the resident from the facility and notifying when the resident would be leaving the facility to be transferred to another facility. This failure could place residents at risk of being discharged without a safe and effective transitions of care.

Inspectors wroteBased on observation, interview and resident review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 10 residents (Residents #1, #2 and #3) reviewed for ADL care. The facility failed to ensure Residents #1, #2 and #3 received baths or showers as scheduled. This failure could place residents at risk of embarrassment and unidentified skin issues .

Inspectors wroteBased on interview and record review the facility failed to establish a grievance policy to ensure the prompt resolution of all grievances regarding the resident rights and maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision for 1 of 7 residents (Resident #1) reviewed for grievances. The facility failed to resolve grievances filed between 11/13/24 and 12/06/24 by the FM for Resident #1 or to maintain copies of the grievances and their resolutions. This failure could place residents at risk of not having their grievances resolved.

Inspectors wroteBased on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 5 residents (Resident #1) reviewed for pressure ulcers. 1. The facility failed to reposition Resident #1 during the overnight shift on 11/25/24 after she developed a stage III pressure ulcer identified on 11/20/24. 2. The facility failed to refer Resident #1 to the RD after the WCD recommended a dietitian consult on 11/19/24. This failure could place residents at risk of worsening pressure ulcers.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for one (Resident #1) of three residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #1. This deficient practice could place residents at risk of not having individualized need met, a delay in services, sustaining injuries, and not receiving adequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 1 of 6 residents (Resident #1) reviewed for physical environment. The facility failed to ensure Resident #1 had a working call light in their room. This failure could place residents at risk of not being able to get assistance when needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for 8 of 16 residents (Resident #10, Resident #26, Resident #63, Resident #60, Resident #36, Resident #96, Resident #16, and Resident #49) reviewed for activities of daily living. The facility failed to ensure Resident #63 had clean and well-groomed hair The facility failed to ensure Resident #36 received regular baths The facility failed to ensure Resident #36, Resident #96, Resident #26, Resident #63, Resident #10, Resident #60, Resident #49, and Resident #16 had nails that were trimmed and groomed. These failures placed residents at risk of not receiving help with activities of daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for one of one dumpster's reviewed for garbage disposal. The facility failed to ensure the dumpster was covered and free of debris. These failures placed residents at risk of an unsightly appearance and pests.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections and follow accepted national standards for three of three Residents (Resident #103, #69 and #58) reviewed for infection control. A) The facility failed to ensure ADON Rehab followed standard precautions during wound care for Resident #103's pressure injury (stage 3 [full thickness tissue loss: fat may be visible, but bone, tendon or muscle is not exposed] pressure wound of the left, lateral (toward the side) ankle when she failed to perform hand hygiene prior to obtaining wound care supplies and performed wound care using contaminated 4 X 4 gauze. [...]

Inspectors wroteBased on interview and record review the facility failed to allow the resident representative the right to exercise the resident's rights to the extent those rights were delegated to the representative for 1 (Resident #39) of 12 residents whose records were reviewed for resident rights. The facility failed to follow through with the request of Resident #39's RP to place an electronic monitoring device in the room. This failure could place residents at risk of not having their responsible party represent them in care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice and the comprehensive care plan for 1 of 10 residents (Resident #14) reviewed for quality of care. The facility failed to ensure nursing staff followed Physician orders for ace wrap bandages to both legs on Resident #14. This failure could place residents at a risk of discomfort and decline in overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #11) of 5 residents reviewed for respiratory care. The facility failed to ensure that Resident #11's Nebulizer tubing and mask, which included the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), was replaced every seven (7) days and bagged. These failures could place residents at risk for respiratory compromise and infection.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 2 (Resident #14 and Resident #68) of 2 resident reviewed for trauma informed care. The facility failed to provide care in a manner to eliminate and / or mitigate triggers for Resident #14 and Resident #68, who had active diagnoses of Post-Traumatic Stress Disorder (PTSD). The facility failed to develop and implement policy and procedures related to trauma informed care. These failures could place residents at increased risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents were provided a nourishing, palatable well-balanced diet that meets daily nutritional and special dietary needs for 1 of 8 (Resident #28) residents reviewed for needs and preferences. The facility failed to ensure Resident #28 received a health shake as ordered as well as other items listed on his meal ticket including cereal, coffee and juice. This failure placed residents at risk of not having their needs and preferences honored.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one of one resident (Residents #2) Reviewed for infection control. CNA B failed to utilize appropriate PPE, when entering Resident #2's room, specifically a face shield or goggles, to prevent the transmission of COVID to the other eleven residents on hall five hundred. This failure could place residents at risk of exposure to infectious diseases. Findings Include: Record review of Resident #2's face sheet, dated 11/20/23, reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses which included pneumonia and on 11/13/23 Covid-19. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for two of two residents reviewed for care plans. (Residents #1, and #2) A) The facility failed to ensure Resident #1's fall care plan intervention were followed by not placing a fall mat in his room. Resident #1 had a fall and died. B) The facility failed to implement Resident #2's fall care plan intervention by not placing a fall mat in her room. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:00 pm. [...]

Inspectors wroteBased on observations, inteviews, and record reviews the facility failed to ensure it provides an environment that is free from accident hazards over which the facility has control and provides supervision and assistive devices to each resident to prevent avoidable accidents for 2 (Resident #1 and Resident #2) out of 15 residents reviewed for accidents and hazards. The facility failed to provide the necessary fall care planned service to Resident #1 by falling to provide the intervention of a fall mat. Resident #1 had a fall, was taken to the hospital, and died. The facility failed to implement interventions for Resident #2 by not placing a fall mat in her room after she had two previous falls, one that resulted in an injury requiring medical intervention. An IJ was identified on 11/08/23. The IJ template was provided to the facility on [DATE] at 5:00 pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for one (Resident #1) of five residents reviewed for care planning in that: The facility failed to include Resident's #1 or their resident representative in their Care Conference meeting on 05/30/23. The failure could affect residents by placing them at risk for not receiving adequate care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of 1 of 5 residents (Residents #1) reviewed for activities in that: The facility failed to provide Resident #1 activities designed to meet her interests and promote physical, mental, and psychosocial well-being. This failure placed residents at risk of boredom, depression, increased behaviors, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents admitted without pressure ulcers do not develop pressure ulcers and once developed, provide care to prevent decline for one of eight residents with pressure ulcers (Resident #63). 1. The facility failed to ensure Resident #63's unstageable pressure ulcer to his heel was assessed and treated daily to ensure Resident #63's pressure ulcer did not decline. 2. The facility failed to update the care plan to indicate a change in the status of the pressure ulcer. 3. The facility failed to ensure that once the pressure ulcer declined, that the Physician treatment orders were followed and failed to notify the Physician of x-ray results indicating osteomyelitis. These failures resulted in an Immediate Jeopardy (IJ) situation on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 11 out of 24 residents (Resident #256 and 12 residents in a confidential group interview) reviewed for grievances. 1. The facility failed to follow-up on grievances Resident #256 made regarding housekeeping issues. 2. The facility failed to routinely address and follow-up on grievances expressed by 11 residents who attended the confidential group meeting. These failures placed residents who reside at the facility at risk of depression, social isolation and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received food that is palatable, attractive and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for palatable and attractive food. 1. The facility failed to provide an entrée at lunch that was palatable as residents were unable to eat the pork chop served because it was tough to chew. 2. The facility failed to provide an entrée at lunch that was attractive and palatable in that the pork was served on one piece of sliced bread and the sliced bread was soggy and inedible from the gravy. This failure could lead to a diminished quality of life and expose residents to food borne pathogens and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in resident ice machines in one (Ice Machine #2) out of two ice machines used to provide ice to the residents. The facility failed to clean and sanitize the resident nourishment room Ice Machine #2 which had black mold growing in the ice bin and on the ice chute. These failures could place the residents who received ice from the ice machine at risk of foodborne illness and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for two (Resident #89, Resident #88 and Resident #256) of residents observed for infection control practices, in that: 1. The facility failed to ensure a sanitary environment for Resident #256 in that the previous resident's urinal and the plastic bag that it was contained in remained in his bathroom after he moved into the room. 2. The facility failed to ensure a sanitary environment for Resident #89 and Resident #88 as feces was observed in their shared shower stall. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents unable to carry out activities of daily living, received the necessary services to maintain good grooming and personal hygiene for 1 of 25 residents (Residents #28) reviewed for quality of care. The facility failed to ensure Resident #28 received showers three times a week. This failure could place residents at risk of skin infection, urinary tract and other infections, and poor self-esteem.