Benbrook Nursing & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 1 (Rooms 210) of 6 rooms observed. The facility failed to maintain Rooms 210 in a safe and sanitary condition when the windowsill was noted to be splintered/cracked, and the window blinds were broken. This failure could place residents at risk for decreased quality of life. Observation and interview on 07/21/26 at 10:23 AM room [ROOM NUMBER] revealed the board of the windowsill was splintered/cracked and under that were three nails approximately 1/4 inch sticking out of the wall and the resident was near where the cracked/splintered board and nails were. The window blinds were also noted to be broken and some if the blind slats appeared to be missing. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' environment remained free of accident hazards for 1 (Resident #1) of 3 residents reviewed for accidents. The facility failed to ensure Resident #1's room was maintained free of hazards when the windowsill had a broken/splintered board and exposed nails on the wall. This failure put the resident at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #2) of two residents observed for catheter care. The facility failed to keep Resident #2's Foley bag below her bladder while in her wheelchair. This failure place residents with catheters at risk for the development of urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure the appropriate information was communicated and follow a written policy on immediate discharge of Resident #1 reviewed for discharge processes. The facility failed to ensure resident was sufficiently prepared and oriented to ensure safe and orderly transfer or discharge from the facility. This failure could place the residents in an unsafe discharge. Findings Included:Record review of Resident #1's MDS Quarterly Set assessment dated [DATE] revealed a [AGE] year-old female admitted to the facility on [DATE] with a BIMS score of 13 (cognitive function is intact). Primary active diagnoses included medically complex conditions; [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident #1, #2 and $4) of 7 residents reviewed for reasonable accommodation of needs. 1. The facility failed to ensure the call light system in Resident #1's rooms was in a position that was accessible to the resident on 07/14/2026. 2. The facility failed to ensure the call light system in Resident #2's rooms was in a position that was accessible to the resident on 07/14/2026. 3. The facility failed to ensure the call light system in Resident #4's rooms was in a position that was accessible to the resident on 07/14/2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so the facility was free of pests and rodents for 3 of 8 residents' rooms and 1 resident hallway (Resident #5, #7,#8 and 200 hall) reviewed for pest control. 1. The facility failed to ensure that Resident #5's room was free from gnats on 07/14/26. 2. The facility failed to ensure that the 200 hall was free from gnats on 07/14/26. 3. The facility failed to ensure that Resident #7's room was free from gnats on 07/14/26. 4. The facility failed to ensure that Resident #8's room was free from gnats on 07/14/26. This failure could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary comfortable environment for residents', staff and the public for 1 of 3 halls (300 Hall) and 1 of 7 rooms (Resident #6's room) reviewed for environment. The facility failed to ensure that the floor in 300 halls was clean was clean and dry on 07/14/26. The facility failed to ensure that the floor in Resident #6's room and its bathroom was clean and dry on 07/14/26. This failure could affect residents living in these halls by placing them at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to store drugs in a safe and secured manner to permit only authorized personnel to have access for 1 of 2 areas (Administrator's desk drawer and oxygen supply room on hall 100). The facility failed on 06/17/2026 to ensure that medications were secured behind a locked mechanism (either in the medication supply room or a medication cart) to ensure the safety of the residents when medications were found in an unsecured desk drawer in an unsecured office and in an unsecured oxygen room on hall 100 with the DON. This failure placed residents at risk of being able to access medications not prescribed to them, with the potential to have side effects or possible overdoses.

Inspectors wroteBased on interview and record review the facility failed to review and revise the resident's comprehensive care plan after each assessment including both the comprehensive and quarterly review assessments for 1 of 2 residents (Resident #1) reviewed for care plans. The facility failed to update Resident #1's care plan to reflect change in behavior needs for a resident with change in condition. This failure put residents at risk of not having their needs met and a decreased quality of life. Findings Included:Record Review of Resident #1's admission Record revealed- [AGE] year old male admitted to the facility on [DATE] with the following diagnosis: paraplegia (a term used to describe the inability to voluntarily move the lower parts of the body). Record Review of Resident #1's Care Plan revision date 04/02/2026 revealed; [...]

Inspectors wroteBased on observation, interview, and record review , the facility failed to provide a safe, clean, comfortable and homelike environment for 5 of 12 residents (Resident # 1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for environment. The facility failed to ensure bathroom floors were clean and in good repair for Resident #1, Resident #2, Resident #3, Resident #4's and Resident #5's bathrooms on the 300 hall male secured unit. This failure could place residents at risk for diminished quality of life due to unclean, unhealthy, and un-homelike living conditions and possible infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all alleged violations involving abuse and neglect were investigated and reported to other officials (including the State Agency) and the administrator of the facility for 2 of 6 residents (Resident #1 and Resident #2) reviewed for reporting. The facility failed to follow its abuse policy by not reporting to the ADM of the alleged incident regarding Resident #1 pulling Resident #2 out their bed, so the ADM could not report the alleged incident to HHSC and the ADM could not investigate the alleged incident. This failure could place residents at risk for abuse and neglect.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents receive treatment and car in accordance with professional standards of practices for 1 of 6 residents (Resident #3) reviewed for quality of care. The facility failed to identify and provide treatment for the wound on Resident #3's hand, that was present for at least 3 days. This failure could place residents at risk for not receiving appropriate treatment and care, developing skin infections and decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 out 3 residents reviewedLVN A failed to notify Resident #1's representative that he was found unresponsive and was transported to the local hospital. This failure placed residents at risk of not having representatives informed of changes in conditions, preventing representatives from being informed and making informed decisions about the residents' care.

Inspectors wroteBased on observation, 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 three of five residents (Residents #1 #2, and #3) reviewed pressure ulcers. 1. The facility failed to consistently identify, measure and stage pressure ulcers on skin assessments for Residents #1, #2 and #3 from January 2026 through March 2026.2. The facility failed to update care plans to reflect current wounds for Resident #1 and Resident #2. 3. The facility failed to ensure wound care to skin and treatment orders for pressure ulcers were provided as directed for Resident #1 and Resident #3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 out of 2 medication carts (MC#1) reviewed for medication storage. The facility failed to ensure the male secure unit medication cart was free of undated and unlabeled insulin on [DATE]. This failure could place residents at risk of poor insulin blood sugar control from expired insulin.

Inspectors wroteBased on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, the facility maintained medical records on each resident that were complete and accurately documented for one of five residents (Resident #1) reviewed for medical records. The facility failed to document physician-ordered weekly weights for Resident #1. The failure could place residents at risk for incomplete clinical records and an inability to accurately monitor nutritional status and changes in condition such as worsening pressure injuries, delayed healing and additional skin breakdown.

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 1 of 5 Residents (Resident#1) reviewed for infection control. The facility failed to maintain a clean resident environment when dried fecal matter was observed smeared on Resident#1's bed frame. This failure could place residents at risk to exposed fecal matter which would increase the risk of health-associated infections. Record review of Resident 1#'s Quarterly MDS Assessment, dated 2/19/2026, reflected a [AGE] year-old female who was admitted on [DATE]. No BIMS score was recorded which indicated there was no interview. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #1) of eight residents observed for supervision. The facility failed to ensure Resident #1, who required 2 staff members for transfers by a mechanical lift, was not transferred by 1 staff member. This failure could place residents at risk of being in an unsafe environment and at risk of accidents and/or injury. Based on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one resident (Resident #1) of eight residents observed for supervision. The facility failed to ensure Resident #1, who required 2 staff members for transfers by a mechanical lift, was not transferred by 1 staff member. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for 2 (Resident #1's room and Resident #3's room) of 5 residents room reviewed for pestThe facility did not ensure Resident #3's room was free of roaches and Resident #1's room was free of gnats. This failure could place residents at risk for uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received food that was appetizing, appealing, and proper temperature prior to serving. The facility failed to ensure milk was at a safe temperature before serving. The facility failed to ensure the dinner roll item was appealing and appetizing food item. The facility failed to ensure the baked potatoes were appealing texture. This failure could result in residents' not being provided food that is nutritious and appealing, resulting in a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen.1. The facility failed to ensure the stand-by freezer food items were dated, labeled, and secured.2. The facility failed to ensure the stand-by refrigerator food items were dated, labeled, and secured.3. The facility failed to ensure the dry storage food items were dated, labeled, and procured.4. The facility failed to ensure that canned good food items were free of dents.5. The facility failed to ensure that held food items were covered prior to serving. These failures could place residents at risk for foodborne illness and foodborne intoxication.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a clean, functional, homelike environment for 2 of 4 shower rooms, 4 of 10 Residents (Resident 10, 53, 59, 78) reviewed for sanitary, functional, and homelike environment, as evidenced by: 1. Residents #10 and #53 had a broken toilet on 9-10-2025, causing the odor of human waste for over a week, forcing the residents to go to the shower room to use a toilet. When the shower room was in use, the residents had to wait to use a toilet. 2. The facility failed to maintain functional plumbing in the 100-Hall shower room, in which the water did not get hotter than 76.5 degrees Fahrenheit. 3. The facility failed to maintain functional plumbing in the 200 Hall Shower room, which had broken shower faucets, and the water could only be adjusted in the back by turning the main shower valves hot and cold. 4. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety for 2 of 8 rooms (room [ROOM NUMBER] and 201) and for 4 of 8 Residents (Resident #12, # 22, 59 and #78) reviewed for refrigerators in the rooms. 1. Facility failed to monitor refrigerator temperature on 09/05/25, 09/06/25, 09/07/25, 09/08/25, and 09/09/25 in room [ROOM NUMBER] and room [ROOM NUMBER] 2. Facility failed to monitor and did not put thermometers or maintain temperature logs in Resident #59's and Resident #78's refrigerators. 3. Facility failed to monitor temperature and/or maintain temperature logs for Resident #12's and Resident #22's refrigerators. These failures could affect residents by placing them at risk for food-borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility must properly dispose of garbage and rubbish in accordance with current state laws for 1 of 1 dumpster reviewed for garbage disposal. The facility failed to ensure all garbage items were placed into the dumpster and the dumpster doors were closed and secured. This failure could place residents at risk of infection and result in a pest infestation from improperly disposed garbage.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's right to be free from verbal abuse for 1 of 4 residents (Resident #49) reviewed for abuse. The facility failed to ensure Resident #49 was free from verbal abuse by Resident #87 on 8/29/25 and 9/6/25. This could place residents at risk of abuse and psychosocial harm.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials including to the State Survey Agency in accordance with State law through established procedures, for 2 of 4 residents (Resident #49) reviewed for abuse. The facility failed to ensure a resident-to-resident altercation that occurred on 08/29/25 was reported to the State Survey Agency. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to complete and implement a comprehensive person-centered care plan for each resident to meet the resident's medical, nursing, therapeutic, and psychosocial needs in order to attain or maintain the resident's highest practicable well-being for one resident (Resident #16) of seven residents reviewed for care plans. The facility failed to complete care plans addressing Resident #16's history of abuse and PTSD. This failure could affect residents by placing them at risk for not receiving care to maintain and/or reach their highest practicable mental and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #83) of one resident reviewed for quality of care. The facility failed to monitor Resident #83's blood glucose levels before administering insulin. This failure could place residents at risk for not receiving appropriate care and treatment and decreased quality of life.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to provide appropriate services to prevent complications of enteral feeding for 1 of 1 resident (Resident #8) observed for medication administration via gastrostomy tube. 1. LVN D did not raise the head of bed during medication administration and water flush via G-tube for Resident # 8. Resident #8 was laid flat on his back. 2. LVN D did not clean the syringe and plunger before placing it in the sealed bag after administering medications via G-tube to Resident #8. 3. Facility failed to obtain orders to elevate the head of bed to at least 30-45 degrees up for Resident #8 who received continuous feedings via G-tube. 4. Facility failed to care plan to elevate the head of bed to at least 30-45 degrees up for Resident #8 who received continuous feedings via G-tube. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the medication cart for 1 of 3 medication carts (Med Cart B) reviewed for storage of medication. 1. LVN E failed to ensure Med Cart B was kept locked and under direct observation where residents and unauthorized staff could access it outside room [ROOM NUMBER]. These failures could give access to unauthorized persons, as well as medications may not be maintained at their best therapeutic level.

Inspectors wroteBased on interview and record review, the facility failed to ensure required in-service training for nurse aides was completed for 2 of 5 CNA's (CNA K and CNA L) reviewed for training. The facility failed to ensure nurse aides received no less than 12 hours of training annually. This failure could place residents at risk of abuse, neglect, and exploitation and receiving poor quality of care by untrained staff.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Resident #1) of five residents reviewed for elopement. The facility failed to prevent Resident #1 from eloping from the facility on an unknown date in July 2025. The failure could place residents at risk for possible elopement, serious injuries, and harm. An Immediate Jeopardy (IJ) was identified on 08/08/25. The IJ template was provided to the facility on [DATE] at 3:32 pm. While the IJ was removed on 08/09/25, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm, and a scope identified as isolated due to the facility's need to evaluate the effectiveness of the corrective systems.

Inspectors wroteBased on observation, interview, and record review, the facility failed to, in response to allegations of abuse or neglect, ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for reporting of abuse. The facility failed to report to the State Survey Agency the elopement of Resident #1 during July of 2025. This failure could place residents at risk for unresolved or future abuse or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to, in response to allegations of abuse or neglect, have evidence that all alleged violations were thoroughly investigated, prevent further potential abuse and neglect while the investigation was in progress, report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and take appropriate corrective action if the alleged violation was verified one (Resident #1) of five residents reviewed for reporting of abuse. The facility failed to investigate and report to the State Survey Agency the results of the investigation of the elopement of Resident #1 during July of 2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, clean, comfortable and homelike environment, allowing the resident to use his or her personal belongings to the extent possible for two of three shower rooms reviewed for environmental concerns. 1. The facility failed to ensure the toilet in the 200 Hall shower room was operational and did not contain a dried brown substance (appeared to be feces) which was covered by a clear plastic trash bag. 2. The facility failed to ensure the 200 Hall shower room did not have a hole in the wall of which exposed the plumbing. 3. The facility failed to ensure the toilet in the 100 Hall shower room was operational which covered by a clear plastic trash bag. These failures could place residents at risk of living in an unclean, uncomfortable and unhomelike environment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that licensed nurses had the specific competencies and skills sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care and nurse aides were able to 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 two of two medication aides (MA E and MA C) and two of three nurses (LVN A and LVN D ) reviewed for competent nursing staff . The facility failed to ensure staff knew how to identify an overfilled sharps container. This failure could place residents at risk of laceration or stick by sharps .

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 Resident (Resident #1) of seven residents reviewed for infection control. -The facility failed to follow the physician's order for contact isolation for Resident #2, who was diagnosed with ESBL, when there were no effective interventions in place to keep the resident isolated in her room and prevent the spread of the infection. This failure placed residents at risk for the spread of infections and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one resident (Resident #2) of five reviewed for accidents. -The facility failed to ensure Resident #2 was provided with adequate supervision to prevent the misuse of a smoking product that contained THCA. This failure could place residents at risk for accidents that could lead to serious injury or harm.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to In accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 of 5 residents (Resident #1) reviewed for shower documentation. The facility failed to ensure documentation reflected Resident #1 received showers as scheduled and desired. This failure affected residents by placing them at risk for discomfort, diminished self-esteem, and decreased quality of life. Findings Included: Record review of Resident #1's Face Sheet dated 4-24-2025 revealed a [AGE] year-old female who admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was provided for 3 of 4 (Resident #1, #2, and #3) shared resident bathrooms and for 1 of 3 (Resident #10) residents rooms reviewed for environmental conditions. 1. The shared bathroom for Residents #1, #2, and #3 had dark brown dried substances on the toilet, the floor, and the wall. 2. Resident #10's room featured a blanket covering the air condition window unit and a towel placed on the base of the windowsill. Additionally, there were two openings in the wall behind the unoccupied bed B in the same room. These failures could affect residents and place them at risk of feeling uncomfortable as a result of living in an unclean and unsanitary environment and living in a room that showed signs of poor maintenance.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 4 of 4 Residents (Resident #6, Resident #7, and Resident #9) reviewed for smoking, and 1 of 1 Resident (Resident #4) reviewed for environment. The facility failed to ensure Residents #6, Resident #7, and Resident #9 were provided supervision while smoking. The facility failed to ensure Residents #6, Resident #7, and Resident #9 were accurately assessed for smoking. The facility failed to ensure Resident #9 was assessed for smoking per facility policy. The facility failed to ensure Resident #4 did not have an electric kettle in her room on the secure unit. These failures could place residents at risk of harm, injury, or accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 1 (Resident #4) resident reviewed for misappropriation of property. The facility failed to ensure CNA B did not take Resident #4's debit card to buy the resident items and for CNA B's personal use. The noncompliance was identified as PNC. The noncompliance began on 11/20/2024 and ended on 12/04/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk exploitation and misappropriation of property.

Inspectors wroteBased on observation and interview, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 of 5 residents (Resident #5) reviewed for ADLs. The facility failed to ensure Resident #5's nails were trimmed, and beard shaved. These failures could place residents at risk of infection and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure a resident did not develop pressure ulcers/injuries (PU/PIs) unless clinically unavoidable and that the facility provided care and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new pressure ulcers/injuries from developing for 1 (Resident #1) of 7 residents reviewed for pressure ulcers/injuries. 1. The facility failed to perform complete and accurate skin assessments for Resident #1, following LVN A's skin assessment on 11/06/24 which revealed moisture associated skin damage to Resident #1's buttocks. These failures placed residents with pressure wounds at an unnecessary risk of complications such as pain, acquiring new wounds, worsening of existing wounds, and infection.

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 necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs. (Resident # 1). The facility failed to ensure staff provided Resident #1 with timely incontinence care before he ended up with feces on his hands, fingers, and hip. This failure could place residents who need assistance from staff for toileting at risk for embarrassment, rashes, infections, discomfort, and skin break down.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for one (Resident #1) of 3 residents reviewed for resident call system. The facility failed to ensure Resident # 1's call light system (in room system, outside the resident door, and nurse station) was working properly. This failure could place resident at risk for delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on 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 each resident for one (Resident #1) of nine residents reviewed for pharmacy services. The facility failed to order Resident #1's routine Oxycontin timely to prevent three missed doses, 5:00 AM and 5:00 PM on 09/26/2024 and 5:00 AM on 09/27/2024. This failure placed residents at risk of worsening and/or exacerbation of their pain and medical conditions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for 2 of 8 residents (Residents #17 and #25) reviewed for Comprehensive Care Plans. The facility failed to complete a comprehensive care plan for Residents #17 and #25. This failure could place residents at risk of not receiving necessary care and services.

Inspectors wroteBased on interview, observation, and record review, the facility failed to use the services of a registered nurse for 8 consecutive hours 7 days a week for 2 of 4 quarters of 2024 (Fiscal Year Quarter 2 January 1-March 31, and Quarter 3 April 1-June 30) PBJ reports reviewed for RN coverage. The facility did not have RN coverage for 8 consecutive hours on weekends for: 01/06/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/20/2024, 01/21/2024, 01/27/2024, 01/28/2024, 02/03/2024, 02/04/2024, 02/10/2024, 02/11/2024, 02/17/2024, 02/18/2024, 02/24/2024, 02/25/2024, 03/02/2024, 03/03/2024, 03/09/2024, 03/10/2024, 03/16/2024, 03/17/2024, 04/06/2024, 04/07/2024, 04/08/2024, 04/13/2024, 04/14/2024, 04/20/2024, 04/21/2024, 04/27/2024, 04/28/2024, 05/04/2024, 05/05/2024, 05/11/2024, and 05/12/2024. This failure could place residents at risk of lack of nursing oversight and higher level of care needed.

Inspectors wroteBased on interview, and record review the facility failed to recognize the resident had the right to designate a representative, in accordance with State law and any legal surrogate so designated may exercise the resident's rights to the extent provided by state law and the facility must treat the decisions of a resident representative as the decisions of the resident for one (Resident #1) of three residents reviewed for resident rights. The facility failed to include Resident #1's RP when Resident #86 was asked to sign a disenrollment form in order to change her Medicare insurance. This failure could place residents at risk of not having their RP included to make informed decisions regarding their care resulting in delayed treatment or a decline in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 1 of 25 residents reviewed for accommodation of needs. The facility failed to ensure Resident #35's call light was within reach of the resident. This failure could affect residents who needed assistance and could result in their needs not being met.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident, for 1 of 8 residents (Residents #17) reviewed for baseline care plans. The facility failed to ensure Resident #17's baseline care plan was completed. This failure could affect newly admitted residents and place them at risk of not receiving appropriate interventions to meet their current needs and communication among nursing home staff to ensure their immediate care needs were met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the facility's only garbage storage dumpster, and surrounding enclosed area, was maintained in a sanitary condition to prevent the attraction, nesting, and accumulation of pests. The facility failed to ensure trash was not left outside of the dumpster on the ground. These failures could place residents at risk of contracting disease by attracting pests, disease carrying rodents, and having debris dangerous to residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 3 of 6 residents (Residents #1, #2, #3) reviewed for effective pest control. The facility failed to maintain an effective pest control program to ensure the facility was free of flies and gnats for Resident #1, #2, and #3's rooms. This failure could place the residents at risk for an unsanitary environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment; for 1 of 6 residents (Resident #1) reviewed for environment. The facility failed to ensure Resident #1's floor was clean from a dried yellowish liquid substance which had the smell of urine. This failure could put residents at risk for unsanitary living conditions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, comfortable, and homelike environment for 2 (Resident #1 and Resident #2) of 6 residents reviewed for environment. The facility failed to provide the necessary housekeeping and maintenance services to ensure Resident's #1 and #2's door opened without resistance. This failure placed residents who resided in the facility at risk of for diminished quality of life.

Inspectors wroteBased on record reviews and interviews, the facility failed to maintain the residents right to be free from verbal abuse for one of five residents (Resident #3) reviewed for Abuse. The facility failed to prevent Certified Nursing Aide A from verbally abusing (cursing) Resident #1. This deficient practice could place residents at risk for decreased quality of life, depression, and psychosocial harm. Review of Resident #3's admission Record reflected a [AGE] year-old male with an admission date of 10/19/2023 with the following diagnoses; A primary diagnosis of polyneuropathy, depression, cellulitis of right lower limb. Review of Resident #3's Care Plan dated 11/04/2023 reflected: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide adequate supervision for 1 of 10 residents (Resident #1) reviewed for wandering and elopement risk. The facility failed to implement effective interventions for Resident #1 identified as at-risk for elopement and had a history of elopement. On 12/03/23 at approximately 1:15 PM, Resident #1 was demonstrating exit-seeking (actively trying to leave the boundaries of a particular area) behaviors by attempting to go out the exit door when the alarm sounded off. LVN A verbally redirected Resident #1 to come to the nurse's station. On 12/03/23, Resident #1 eloped (an unauthorized departure of a resident from an around-the-clock care setting) from the secured unit unnoticed by facility staff. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that in accordance with accepted professional standard and practices, medical records were complete, accurately documented and included a record of the resident's assessments for one (Resident #1) of five residents reviewed for clinical records accuracy. 1. The facility failed to document when Resident #1's PRN narcotic pain medication (Hydromorphone and Oxycodone) was administered on the MAR on numerous occasions from 10/19/23 through 11/15/23. The narcotic count sheet was being signed off on that the medication was being taken from the narcotic blister pack, but the MAR did not reflect it was given. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident has the right to be informed in advance, by the physician or other practitioner or other professional of the risks and benefits of proposed care, treatment and treatment alternatives for one (Resident #1) of five residents reviewed for consent of psychoactive medications. Resident #1 did not consent for the use of Cymbalta (antidepressant) when his Prozac was discontinued after admission to the facility without his knowledge or input. He unknowingly received Cymbalta and did not feel like it was helping with his depression. The failure could place residents prescribed antipsychotic medications at risk of receiving a medication without consent, which could cause duplicate therapy, sedation, side-effects and uncomfortable emotional changes.

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 centralized staff work area, for 1 of 24 residents (Resident #13) reviewed for resident call system. The facility failed to ensure Resident #13 had a working call light in her room. This failure could place residents at risk of not being able to get assistance when needed.