Austin Wellness & Rehabilitation

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from abuse for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to closely supervise and monitor after Resident #1 was involved in a physical altercation with Resident #2 on [DATE]. Resident #1 was hospitalized and received staples to his scalp and ear and a laceration to his face. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 8:30 PM. A plan of removal was requested. While the IJ was removed on [DATE], the facility remained at a level of no actual harm at a scope of isolated that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systemsThis failure could place residents at risk for physical, mental, and/or psychosocial harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately. The failure could affect residents by placing them at risk for food-borne illnesses and food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 1 of 4 (ADON ) staff reviewed for staff qualifications. The facility failed to ensure ADON had a valid nursing license to practice and was not expired on [DATE]. This failure could place residents at risk for not receiving nursing services by a licensed nurse.

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 a centralized staff work area from each resident's bedside for 4 of 34 residents (Residents # 3, # 36, #46 and # 56) reviewed for call lights. The facility failed to ensure the call light system was accessible to Residents # 3, # 36, #46 and #56. These failures could place residents at risk of not being able to call for staff assistance to meet care needs or at risk of injury, pain, hospitalization, and a diminished quality of life. Record review of a face sheet dated 05/07/2026 indicated that R #3 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment for 1 of 8 (Resident #13) residents reviewed for homelike environment. The facility failed to ensure that shower curtains did not contain brown, unidentifiable substances and that the shelf in the shower room did not contain a yellow unidentifiable substance. These findings could place residents at risk for living in an environment that is not homelike.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 5 of 8 residents (Resident #12, Resident #45 , Resident #86 , Resident #95 and Resident#57, ) reviewed for respiratory care. The facility failed to ensure that :The oxygen cannula, nebulizer masks and tubing of Resident #36 and Resident #95 were stored safely in protective bags. 'oxygen in use sign board displayed in the rooms of Resident #12, Resident #57, and Resident #86These failures placed residents at risk for fire safety and respiratory infections through contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were labeled and stored in accordance with currently accepted professional principles for 2 of 4 medication (Med) carts (Med cart 2100 and Med cart 2400) reviewed for storage. The facility failed to ensure MA B did not store his personal belongings in the Med cart 2100 and Med cart 2400on 05/06/26. These deficient practices could place residents at risk of receiving cross-contaminated medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide drinks, including water and other liquids consistent with resident needs and preferences and sufficient to maintain resident hydration for 3 of 8 residents (Residents #30, #56 and #90) reviewed for hydration, in that: The facility failed to ensure R #30, R# 56, R #90 had access to water and/or beverages in their rooms between meals. These deficient practices could affect resident's hydration and lead to discomfort, dehydration, and/or a diminished quality of life. Record review of R# 30's face sheet dated 05/07/2026 revealed a [AGE] year-old male with an admission date of 09/02/2025 with diagnoses which included: Hypertension (High pressure in the arteries (vessels that carry blood from the heart to the rest of the body). [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 3of 4 residents (Resident #45 Resident # 28 and Resident #56) reviewed for incontinence care and infection control. The facility failed to ensure that :CNA G and CNA H handling personal care items with clean gloves while providing incontinent care for Resident #45. MA I sanitized the blood pressure monitor before and in-between use on Resident #56and Resident #28, while obtaining blood pressure. This failure could place the residents at the facility at risk of transmission of disease and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had the right to manage their financial affairs and to know in advance what charges a facility may impose against a resident's personal funds for 1 of 8 (Resident #70) residents reviewed for personal funds. The facility failed to distribute Resident #70's personal needs allowance in full. This failure placed residents at risk of not having access to their funds and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #1) reviewed for privacy. The facility failed to ensure CNA G and CNA H provided privacy by closing the door and drawing the privacy curtain during incontinent care for Resident #45. This failure could place residents at risk of lack of privacy and not having residents' rights acknowledged.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 2 of 8 (Resident #9 and Resident #34) residents reviewed for activities of daily living. The facility failed to ensure Resident #9 and Resident #34's nails were trimmed and clean. This failure placed residents at risk for poor hygiene and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident received care consistent with professional standards of practice to prevent pressure ulcers for 1 of 8 residents (Resident #97) reviewed for skin assessments. The facility failed to assess Resident #97's skin weekly, as required by the facility's policy, from December 2025 to May 2026 This failure placed residents at risk for unidentified skin issues.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plan revisions. The facility failed to ensure that Resident #1's care plan was comprehensive and complete, reflecting his complex active medical conditions. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interview and record review the facility failed to develop the comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure that Resident #1's comprehensive care plan was completed within 7 days after completion of the comprehensive assessment, completed on 02/05/26. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a complete care plan that meets all of a resident's needs, with timeframes and actions that can be measured for 1 of 8 residents (Resident #1) reviewed for care plan. The facility failed to develop Resident #1's care plan to reflect refusals of showers and interventions which included skin assessment and reduction of risk for skin breakdown. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed make sure that drugs are stored properly and only authorized persons have access for 1 of 3 medication carts (MC #1) reviewed for drug storage and labeling. The facility failed to ensure MC #1 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, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for one (1) (Resident #1) of six (6) residents reviewed for abuse and neglect. The facility failed to thoroughly investigate an alleged abuse incident reported by Resident #1 on 09/15/2025. The facility did not notify law enforcement. This deficient practice placed all residents at risk of harm from abuse due to not having a thorough investigation done for an alleged abuse. Findings Include: Record review of Resident #1's face sheet, dated 09/16/2025, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of three residents reviewed for care plan. The facility failed to develop Resident #1's comprehensive care plan to address all Resident #1's care needs. Resident #1's comprehensive care plan did not address the need for pain medication / management, risks for pressure ulcer development, assistance needed for ADL care, incontinence to bowel and bladder, medications Resident #1 was taking to manage disease processes, Hospice care, reason for oxygen therapy, DNR status, fall risk, elopement risks. This deficient practice could place residents at risk for not receiving necessary care and services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of communicable diseases for 3 or 3 residents (Resident #1, Resident #2, and Resident #3) reviewed for infection control.1. CNA A failed to change gloves when providing incontinent care to Resident #1 on 08/07/25.2. CNA B failed to conduct hand hygiene between glove changes and wiped from back to front while providing incontinent care to Resident #2 on 08/07/25.3. LVN C failed to change gloves after touching a soiled brief and before applying a clean brief to Resident #3 on 08/07/25. Thes failures could place incontinent residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 4 residents (Resident #1, Resident #2, Resident #3). The facility failed to ensure the environment was clean, sanitary and homelike for 3 of 4 residents (Resident #1, Resident #2, Resident #3) reviewed for environment, in that:. 1. There was a strong smell of urine throughout the facility. These failures could place residents at risk for not living in a comfortable and homelike environment, affecting their rights.

Inspectors wroteBased on observations, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for 7 of 12 (Resident # 4, Resident #27, Resident #41, Resident # 48, Resident # 66, Resident # 76 and Resident #186) residents reviewed for resident rights. 1. The facility failed to promote Resident # 4, Resident #27, Resident #41, Resident # 48, Resident # 66, and Resident # 76's dignity while dining when staff did not complete serving meals to one table at a time before moving to the next table to serve meals without finishing serving meals at the prior table. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all residents had the right to request, refuse, and/or discontinue treatment to participate in or refuse to participate in experimental research, and to formulate an advance directive for 5 of 30 residents (Residents #22, #81, #235, and #40) reviewed for advanced directives. 1. The facility failed to ensure Resident # 22's admission face sheet included an accurate advanced directive, as it listed both Full Code and a DNR (Do Not Resuscitate) on file. Resident # 22's care plan included documentation of the DNR on file. 2. The facility failed to ensure Resident # 81 had documentation on file in their records concerning their wishes on their advance directive status. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally for 3 (Resident # 10, Resident # 35, and Resident # 42) of 10 residents reviewed for food preferences and for 1(Lunch on 3/4/25) of 5 meals observed in that: 1. The test tray of the lunch meal on 03/04/25 was unappetizing in appearance (no seasoning observed, and the pureed food items had all run together) a. the rolled silverware for the regular texture tray napkin was wet and soggy b. the pureed carrots for the pureed texture tray tasted only of very tart orange juice c. the pureed dinner roll tasted very doughy and underdone. 2. [...]

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 DS J properly used proper hand hygiene during food preparation. 2. The facility failed to ensure DS L and DS H wore a beard guard while in kitchen. 3. The facility failed to ensure all foods were labeled and dated in the kitchen. 4. The facility failed to ensure all items were covered and stored properly in the kitchen. 5. [...]

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 5 of 8 staff reviewed for infection control. 1. The facility failed to ensure CNA A conducted hand hygiene when passing resident lunch trays . 2. The facility failed to ensure MA L sanitized the blood pressure cuff after checking a resident's blood pressure . 3. The facility failed to ensure CNA D, LVN B, and the AD conducted hand hygiene between residents during lunch tray pass . These failures could place residents at risk of transmission of disease and infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 7 residents (Residents #38) reviewed for resident rights in that: The facility failed to ensure Residents #38 had a call device within reach from 3/3/25-3/6/25. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 of 10 residents (Resident #185, and Resident #135) reviewed for baseline care plans. The facility failed to ensure baseline care plans were completed for Resident #185 and Resident #135. The facility failed to develop a baseline care plan that reflected the need for Resident #185's wandering and agitation for Resident #185 The facility failed to develop a baseline care plan that reflected the individuals needs of Resident #135. This failure puts all residents at risk of not getting their needs met.

Inspectors wroteBased on observation, interview and record review 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, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 8 residents (Residents #31, and #38) reviewed for activities. The facility failed to provide Residents #31 and #38 with individual or group activities. This failure could place residents at risk for a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for one of eight residents (Resident #37) reviewed for nutrition status maintenance. 1. The facility failed to obtain consistent weights for Resident #37. These failures could place residents at risk of further weight loss, malnutrition, and a decreased quality of life. Record review of the dietitian's orders, dated 01/22/25, stated resident was on house supplement with meals. Recommended 1:1 assistance with meals. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 5 residents (Resident #186 and Resident #32) reviewed for pharmaceutical services. The facility failed to document controlled medications from the medication cart on the narcotic count sheets for Resident #186 and Resident #32. This failure could place residents at risk to medication errors .

Inspectors wroteBased on observations, interviews, 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 infection for 4 of 6 residents (Resident #1, Resident #2, Resident #3 and Resident #4) reviewed for infection control. The facility failed to wear PPE when providing high contact resident care (dressing, bathing, transfers, wound care, device) to Resident #1, #2, #3 and #4. The facility failed to have signage on resident doors that reflected PPE was required for high contact care for Resident #1, #2, #3 and #4. The facility failed to educate staff on infection control procedures related to Enhanced Barrier Precautions (EBP). [...]

Inspectors wroteBased on interviews and record review, the facility failed to designate an Infection Preventionist that was qualified by education, training, experience, or certification, and who completed specialized training in infection prevention and control, for one of one facility. The facility did not designate a qualified Infection Control Preventionist. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services to maintain grooming and personal care for one of seven residents (Resident #1) reviewed for ADL care in that: The facility failed to provide residents with care and services related to activities of daily living, Resident #1 had long and dirty fingernails. This deficient practice could affect residents who were dependent on assistance with ADL's and could result in poor care and risk for skin breakdown and feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on interview and record review, the facility 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 three (Residents #1, #2 and #3) of seven residents reviewed for baseline care plans. The facility failed to develop baseline care plans for Resident #1, #2, and #3. This deficient practice could place residents at risk of not having individualized needs met, a delay in services, sustaining injuries, and not receiving adequate care.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services to meet the needs of each resident for one (Resident #1) of seven residents reviewed for medication administration. The facility failed to ensure Resident #1 was administered her prescribed Ertapenem Sodium Injection Solution (used to treat certain serious infections). This deficient practice could place residents at risk of not being provided their routine and emergency drugs and biologicals to meet their needs, infection, or having medical conditions worsen or be exacerbated.

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 two (Resident #1 and Resident #2) of five residents reviewed for accidents and hazards. The facility failed to: - Address or put in place new interventions when Residents #1 and #2 had a change-in-condition and began experiencing more frequent falls in a short time-frame. - Implement the new intervention of a helmet that was documented in a nursing noted for Resident #2 after a fall on 07/27/24. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 09/18/24 at 9:15 AM. [...]

Inspectors wroteBased on observation, interview, 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' choices for two (Resident #1 and Resident #2) of five residents reviewed for quality of care. The facility failed to conduct a fall/skin assessment or conduct neuros consistently after unwitnessed falls for Residents #1 and #2. These deficient practices could place residents at risk of harm, injuries, or hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure that medical records were accurately documented for one (Resident #3) of five residents reviewed for accurate medical records. The facility failed to ensure Resident #3's medical chart contained any documented nursing progress notes. This deficient practice could result in errors in care and treatment.

Inspectors wroteTX00507691 Census of 100 Based on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR level II determination for 1 of 1 resident reviewed for PASRR. The facility failed to ensure Resident #1 was referred for Specialized ST, OT and PT evaluations and services after these were agreed upon during his IDT by the due date of 05/10/2024. This failure could place residents at risk of decline in functional ADLs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for four (Resident #2, Resident #4, Resident #5, and Resident #6) of thirteen residents in that: The facility failed to ensure the main dining room and resident community television area by nurses' station 2 maintained a temperature range of 71 to 81°F for Residents #2, Resident #4, Resident #5, and Resident #6. The failure could place residents at risk of illness due to heat and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of three (Resident #1 and Resident #2, and Resident #3) of ten residents reviewed for medication administration, in that: The facility failed to label multi-dose, insulin medications according to recommendations and professional standards of practice in one of four medication carts reviewed for medication storage for Residents #1, Resident #2, and Resident #3. This deficient practice placed residents at risk for administration of expired medications and decreased therapeutic effects of administered medications.

Inspectors wroteBased on record review, observations and interviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the residents' rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) experiencing falls. The facility failed to include frequent falls as a focus area to provide possible preventive interventions despite the resident having serious injuries from falls in his recent history, prior to admission and multiple falls since his admission. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 06/01/24 at 6:03PM and the facility was notified and given an IJ template. [...]

Inspectors wroteBased on record reviews, observations and interviews, the facility failed to ensure a resident's environment remained free of accident hazards and residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not have repeated falls without attempts to decrease the severity and frequency of falls that continued to occur despite the same two interventions used each time a fall occurred. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 06/01/24 at 6:03PM and the facility was notified and given an IJ template. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both comprehensive and quarterly review assessments, for 5 (Residents #1, #2, #3, #4, and #5) of 6 residents reviewed for care plans, in that: Residents #1, #2, #3, #4, and #5's comprehensive care plans were not reviewed and revised after their quarterly MDS assessments were completed. These deficient practices could place residents at risk of current needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 3 residents (Resident #1) reviewed for PASRR. The facility failed to ensure Resident #1 was referred for Specialized OT and PT evaluations and services after these were agreed upon during his IDT meeting on 12/11/23. This failure placed Resident #1 at risk of decline in functional ADLs.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident who was unable to conduct activities of daily living independently, received the necessary services to maintain good grooming and personal hygiene for 2 of 4 residents reviewed for quality of life (Resident #3 and Resident #4). 1. The facility failed to provide scheduled bath/showers for Resident #3. 2. The facility failed to provide scheduled bath/showers for Resident #4. These failures could place residents who required assistance from staff for ADL's at risk of poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prepare food in a form to meet individual needs for 1 of 4 (Resident #5) residents observed for dietary needs. The facility failed to provide a mechanical soft diet with pureed meats for Resident #5 and served her chopped meat during lunch and an entire pureed meal for dinner. This failure could contribute to causing a resident to choke and poor food intake.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for elopement. Resident #1 walked out of the facility unattended on 03/15/2024 at about 9:00PM until the police found him at about 10:00 PM from a place approximately 1.5 miles away from the facility. EMS organized by the police to take him to the hospital and at the hospital it was confirmed that resident had hairline fracture above the left eye and cheek with lacerations on left eye lid, left wrist, and lower and upper lips, and abrasions on hands. The facility staff was not aware the resident was missing until the family called the facility. This was determined to be an Immediate Jeopardy (IJ) on 03/25/24 at 4:55 PM. The Administrator and DON were notified. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 3 (Resident #1, 2 and 3) of 4 residents and 1 of 1 hallway observed for a clean environment. 1. The facility failed to ensure Resident #1, #2, and #3's bedroom floor was clean. 2. The facility failed to ensure the hallway floor was clean and had no foul odors. This deficient practices could place residents at risk of a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to include effective communications as mandatory training for 13 of 16 employees (CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, FSS, Act Dir, RN P, LVN Q, and LVN S.) The facility failed to provided CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, FSS, Act Dir, RN P, LVN Q, and LVN S with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 6 of 16 employees (CNA G, CNA J, LVN N, RN P, LVN Q and LVN S) reviewed for training, in that: The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA G, CNA J, LVN N, RN P, LVN Q and LVN S. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 16 of 21 employees (CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S. This deficient practice could place residents at risk for not receiving safe and appropriate care by adequately trained staff and could result in a decline in health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 7 of 16 staff (CNA G, CNA J, LVN N, RN P, LVN Q, LVN R and LVN S) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to CNA G, CNA J, LVN N, RN P, LVN Q, LVN R and LVN S. This failure could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on interview and record review the facility failed to communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for for 16 of 21 employees (CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S) reviewed for training, in that: The facility failed to ensure that compliance and ethics training was provided to CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, CNA L, CNA M, LVN N, LVN O, FSS, Act Dir, RN P, LVN Q, LVN R, and LVN S. This failure could place residents at risk for injury or improper care due to a lack of training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 16 employees (CNA F, CNA G, CNA J, LVN N, RN P, LVN Q, LVN R, and LVN S) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to CNA F, CNA G, CNA J, LVN N, RN P, LVN Q, LVN R, and LVN S. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide reasonable accommodation of resident needs for 1 of 13 (Resident #81) residents reviewed for call lights on the 2100 hall in that: The facility failed to ensure Residents #81's call light was within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed and risk of falling. The Findings Included: [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident #81) reviewed for comprehensive care plans in that: Resident #81's comprehensive care plan did not address the resident's Hospice services. This deficient practice could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 1 residents (Resident # 249) reviewed for oxygen in that: Resident #249's oxygen tubing were not changed as ordered. This deficient practice could affect residents in the facility ordered to receive oxygen therapy as needed and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure nurse aides can demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments and described in the plan of care for 1 of 3 residents (#82) in that: 1. The facility failed to ensure CNA A cleaned Resident #82's penis by changing wet wipes or folding the wet wipe to change surfaces. 2. The facility failed to ensure CNA T cleaned Resident #82's using 1 wipe and moving the wet wipe back and forth at the coccyx area without changing surfaces. These deficient practices affect residents who require peri care and could result in infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in accordance with currently accepted professional principles, for 2 of 3 medication carts observed, in that: 1. The Middle Medication Cart 2200 hall contained eighteen loose medication pills. 2. The Hall Back Medication Cart 2200 hall contained eight loose medication pills. These practices could place residents who receive medications at risk for not receiving the intended therapeutic effects of medications.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation in that: 1. A metal pan covered with white wax style paper covering approximately 6 chicken breasts was placed on a shelf in the bottom of the walk-in cooler, the chicken was removed from the manufacturer's box and was not completely covered or in an enclosed container. 2. Six loaves of raisin bread with no dates or labeling of any type on the individual loaves and when the raisin bread was removed from the original manufacturer's box, placed on a metal tray with the date it was taken out of the freezer by the Food Service Supervisor. These failures could place residents at risk for food-born illness, and food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 2 of 2 facility dumpsters in that: 1. Dumpster #1 had the side door open making trash placed in the dumpster visible for 3 of 3 observations. 2. Dumpster #2 had the top lid open making trash placed in the dumpster visible. These deficient practices could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents, and expose them to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 of 1 resident (Resident # 7) reviewed for hospice services in that: The facility failed to maintain required hospice forms and documentation to ensure residents received adequate end-of-life care. This failure could place the residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

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 to help prevent the development and transmission of infections for 3 of 3 staff (CNA A, CNA T and LVN S) reviewed for infection control, in that: 1. CNA A, while providing peri-care to a male resident, did not change her gloves during the whole procedure. 2. CNA T, while providing peri-care to a male resident, did not sanitize her hands between glove changes. 3. LVN S, while looking at a catheter bag that was hanging from the bed side bottom bed frame and partially touching the floor, did not use gloves while handling the catheter bag and touched the tubing on Resident #7's bed without practicing hand hygiene. These deficient practices could place residents at-risk for infections.

Inspectors wroteBased on interview, and record review, the facility failed to provide resident abuse prevention training to 2 of 21 staff reviewed including CNA G and LVN Q. The facility failed to ensure that 2 of 21 staff reviewed had completed their mandatory abuse annual training. This failure could place residents at risk of being cared for by untrained staff.