Buena Vida Nursing and Rehab-San Antonio

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1 was not left unattended in the shower room during a shower on 07/14/26, which resulted in the resident falling and sustaining a hip fracture which required surgical repair. The noncompliance was identified as PNC. The noncompliance began on 07/14/26 and ended on 07/17/26. The facility corrected the noncompliance before the survey began on 07/22/26. This failure could place residents at risk of experiencing falls, serious injuries, harm or death as a result of a fall.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided 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 1 of 3 residents (Resident #1) reviewed for pharmacy services, in that: The facility failed to ensure Resident #1 received his Ibuprofen 200 mg by mouth on 07/06/2026 at 8:00 a.m. and 4:00 p.m. for inflammation as ordered. This deficient practice and failure could place residents at risk for pain and collapse of daily life because of the pain.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for medical records accuracy. The facility failed to ensure Resident #1's Nursing Assistant ADL Flow Sheets were accurately documented from 4/13/2026 to 5/12/2026. This failure could place residents at risk for an incomplete clinical picture and errors in care and treatment.

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 3 residents (Resident #2, Resident#3, and Resident #4) reviewed of 29 residents reviewed for pharmaceutical services. The facility failed to ensure that Resident #2's, Resident #3's, and Resident #4's narcotic sheets were labeled in way to account for all medications dispensed by pharmacy. This facility failure could affect residents who take narcotics for pain and could result in misappropriation of medications or drug diversion. The Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and to ensure resident receives adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and hazards in that: The facility failed to ensure Resident #1's environment was free of hazards and Resident #1 was adequately monitored. On 2/4/2026 Resident #1 told CNA A she wanted to kill herself. Resident #1 was discovered harming herself by cutting her right wrist with a shaving razor on 2/5/2026. The noncompliance was identified as PNC. The IJ began on 2/4/2026 and ended on 2/8/2026. The facility had corrected the noncompliance before the survey began. This failure could result in residents experiencing suicidal ideations being at risk for harm, injuries, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident receives adequate supervision to prevent accidents for 1 of 11 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure Resident #1 received adequate supervision and did not elope from the facility on 9/05/2025 at approximately 6:15 PM until he was returned to the facility by a visitor at 6:45 PM. The noncompliance was identified as PNC. The IJ began on 9/05/2025 at approximately 6:15 PM and ended on 9/06/2025 at 5:30 PM. The facility had corrected the noncompliance before the survey began. The failure could place residents at-risk of injury or death due to not being adequately supervised.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs for 4 of 11 residents (Residents #1, #2, #3, and #4) reviewed for comprehensive care planning. The facility failed to develop and implement comprehensive care planning for assessed elopement risks of Residents #1, #2, #3, and #4. This failure could lead to residents not receiving necessary care and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to protect the residents' right to be free from neglect for 1 of 8 residents (Resident #1) reviewed for neglect in that: 1. Resident #1 was not provided wound care daily to the left ankle or skin assessments by facility nursing staff from 08/28/2025 - 09/24/2025. Resident #1 was admitted to the hospital on [DATE] for osteomyelitis and had to have a left BKA. 2. Resident #1 went for approximately one month without adequate treatment for wounds which led to infection and right BKA. 3. The facility failed to ensure Resident #1 was provided with wound care to a surgical wound on the resident's right leg. 4. The ADON failed to ensure wound care treatment orders were added to Resident #1's EMR. An Immediate Jeopardy (IJ) was identified on 10/04/2025. The IJ template was provided to the facility on [DATE] at 12:35 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with surgical wounds 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 8 residents (Resident 1) reviewed for surgical wounds in that: Resident #1 did not have weekly skin assessments during the month of September 2025, did not receive care to the right surgical wound as ordered by the physician and was admitted to the hospital on [DATE] with an infection to Resident #1's right below the knee amputation. An Immediate Jeopardy (IJ) was identified on 10/04/2025. The IJ template was provided to the facility on [DATE] at 12:35 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents 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 8 residents (Resident 1) reviewed for pressure ulcers in that: Resident #1 had a Stage IV pressure ulcer on his left ankle and did not have wound treatment orders in the month of September 2025. Resident #1 was admitted to the hospital on [DATE] with osteomyelitis and had a left below the knee amputation on 09/25/2025. An Immediate Jeopardy (IJ) was identified on 10/03/2025. The IJ template was provided to the facility on [DATE] at 4:53 p.m. [...]

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 3 of 8 residents (Resident # 5, 6 and 8) reviewed for infection control in that: Resident #5 had a foley catheter and did not have a sign for Enhanced Barrier Precautions (EBP). Resident #6 had a foley catheter and was observed with her foley catheter tubing touching the floor under Resident #6's wheelchair. Resident #8 had a gastric tube and did not have a sign for Enhanced Barrier Precautions (EBP). This deficient practice could affect residents on enhanced barrier precautions and place them at risk for infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure personal privacy for 1 of 8 residents (Resident #5) observed for foley catheters in that: Resident #5 was observed in bed with her foley bag attached to the side of the bed without a privacy cover, exposing her foley bag contents to the open bedroom door. This deficient practice could affect residents who have foley catheter bags and could result in loss of dignity and low self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the daily nursing staffing formation that included the facility name, the current date, the total number and actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift: registered nurses, licensed practical nurses, certified nurse aides and resident census in a prominent place readily accessible to residents, staff, and visitors for 61 residents in that: The facility failed to post the daily staff posting information on 10/01/2025 and 10/02/2025. This failure could place residents and visitors at risk of not being able to review the facility's daily staffing hours.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 4 of 6 residents (Resident #7, Resident #8, Resident #10, and Resident #35) who were reviewed for resident assessments. 1. The facility failed to document Resident #7's use of anticonvulsant medication on the quarterly MDS assessment. 2. The facility failed to accurately code Resident #8's hypoglycemic medication on the quarterly MDS assessment.3. The facility failed to document Resident #10's use of antiplatelet medication on the quarterly MDS assessment.4. The facility failed to accurately code Resident #35's diagnosis of bipolar disorder on the quarterly MDS assessment. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise the comprehensive care plan after each assessment for 5 of 6 residents (Residents #1, #4, #7, #10, and #35) reviewed for care planning. 1. The facility failed to ensure Resident #1's care plan was accurate to reflect that he was not a smoker.2. The Facility failed to ensure Resident #4's care plan reflected he was on dialysis. 3. The facility failed to ensure Resident #7's care plan was accurate and updated to reflect the type of psychoactive medications prescribed for Resident #7 and the specific side effect monitoring of those medications. 4. The facility failed to ensure Resident #10's care plan was accurate and updated to reflect the type of blood thinning medication Resident #10 was prescribed.5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drug records were in order and that an account of all controlled drugs was maintained and periodically reconciled for 3 of 5 carts (2300/2400 hall nurse cart, 2300/2400 hall medication aide cart, and the 2200/2500 hall medication aide cart) reviewed for pharmacy services. The facility failed to ensure the controlled substance reconciliation logs were signed for accuracy of medication quantities during shift change. This failure could place residents at risk of not receiving their prescribed medications, experiencing untreated pain and anxiety, and a 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 disease and infection for 2 of 8 residents (Resident #3 and Resident #34) reviewed for infection control: 1. The facility failed to ensure staff wore proper PPE while performing wound care for Resident #3. 2. The facility failed to ensure CNA F and CNA G performed hand hygiene between glove changes while performing incontinent care for Resident #34. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 (dry #1, #3, and #4) of 4 dryers reviewed for environment. The facility failed to properly dispose and maintain the lint accumulation in the facility dryers in a timely manner. This failure could put residents at risk for an unsafe and unsanitary environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have the right to be informed of and participate in their 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 they prefer for 1 of 6 residents (Resident #35) whose records were reviewed for informed consent. The facility failed to obtain signed consent prior to administering the psychotropic medication Risperdal (an atypical antipsychotic indicated for the treatment of schizophrenia, bipolar I disorder with acute manic or mixed episodes, and autism-associated irritability) for Resident #35. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for one (Laptop) of three medication cart computers reviewed for confidential medical records. The facility failed to ensure a laptop A was not left open with patient information on the screen. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for 1 of 8 residents reviewed for PASRR (Resident #34). The facility failed to ensure Resident #34 had an accurate PASRR Level 1 Screening indicating diagnoses of mental illness and refer the residents to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 hallways (hallway 2300) observed for accidents and hazards: The facility failed to ensure hallway 2300 did not have a capped lancet lying in the middle of the floor. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #34) reviewed for incontinent care: The facility failed to ensure CNA F did not wipe between Resident #34's gluteal folds from back to front in the wrong direction during incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #4) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #4. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

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 for 2 of 5 medication carts (the 2200/2500 hall medication aide cart and the 2300/2400 hall medication aide cart) assessed for medication storage and labeling. The facility failed to ensure all medications located inside the 2200/2500 hall medication aide cart and the 2300/2400 hall medication aide cart were stored in labeled containers. This failure could place residents at risk of receiving inadequate treatments or ingesting medications for which they were not prescribed.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 6 residents (Resident #35) reviewed for accuracy of records. The facility failed to ensure Resident #35's diagnosis of bipolar disorder was documented on the resident's active diagnosis list, the MDS assessment, and the care plan. This failure could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 8 residents (Resident #1) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an alleged romantic relationship between Resident #1 and LVN A, as reported by Resident #1 to the DON, and LVN A to the ADON. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to ensure that the comprehensive person-centered care plan described services that are furnished to maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans in that: 1. Resident #1's care plan did not indicate that Resident #1 was noncompliant with the facility smoking policy and did not indicate effective interventions for the noncompliance. 2. Resident #1's care plan did not indicate that Resident #1 had verbally disruptive and aggressive behaviors toward staff and others and did not indicate effective interventions for the behaviors. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assured accurate administering of all drugs to meet the needs of residents for 1 of 3 residents (Resident #1) reviewed for medication regimen. 1. LVN B did not administer Resident #1's Hydrocortisone gel to his face within the parameters of the scheduled administration time on 11/15/2024. 2. MA A documented that MA A administered medications to Resident #1 on 11/15/2024 that had not been administered. 3. MA A prepared Resident #1's medications, placed the medications in unlabeled cups and stored the medications in the top drawer of MA A's medication cart on 11/15/2024. 4. MA A was administering Lidocaine 4% patches for Resident #1 instead of Lidocaine gel as ordered. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for 1 of 7 (Resident #1) residents reviewed for quality of care. 1. The facility failed to schedule an ENT appointment for Resident #1 per a physician's order. 2. The facility failed to schedule a Vascular appointment for Resident #1 per a physician order. This failure could affect resident who were referred for services with outside providers and could result in a decline in physical condition.

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 1 of 3 (Resident #3) residents reviewed for medication administration. MA B failed to perform hand hygiene after administering medications to Resident #2 and before administering medications to Resident #3. This failure could place residents receiving medication at risk for cross contamination and/or spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable interior for 1 of 6 resident rooms, observed for housekeeping and maintenance, in that: 1. Resident #2's bed foot board was broken and hanging on the bedframe. 2. Resident #2 was sleeping in bed without linen. These failures could lead to resident injury and a diminished quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 6 residents (Resident #1) reviewed for medical records. Resident #1's Nurse [NAME] for October 2024 for bathing was documented differently from the CNAs October 2024 POC (an electronic record system) documentation. This failure could result in residents not having an accurate overall view of their care and services.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 2 of 3 residents (Residents #1 and #2) reviewed for accuracy of medical records in that: 1. The facility failed to ensure medications prescribed to Resident #1 were documented on the MAR for multiple dates in August 2024. 2. The facility failed to ensure medications prescribed to Resident #2 were documented on the MAR for multiple dates in August 2024. These failures could affect residents whose records are maintained by the facility and could place the residents at risk for errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 1 facility reviewed for safe, clean, comfortable environment, in that: 1. In room [ROOM NUMBER], there were loose tiles around the toilet, the bolt securing the toilet to the flood was rusted, there was an excessive accumulation of dust and debris on top of the mirror above the sink and paper towel dispenser, and the vent located on the wall across from the bathroom had a large accumulation of dust surrounding each opening. 2. A light above the sink in the Secured Unit shower room was not functioning. 3. In the bathroom of room [ROOM NUMBER], the toilet seat had a broken hinge. 4. [...]

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 each resident for 10 of 24 residents (Residents #3, #4, #8, #11, #14, #19, #24, #33, #39, and #46) reviewed for the provision of routine and emergency drugs and biologicals, in that: 1. On [DATE] at 10:54 AM MA B administered Resident #3's baclofen 1 hour and 53 minutes late, and the resident's torsemide (a diuretic used to treat swelling), buspirone, and gabapentin (a medication to treat nerve pain) 53 minutes late. 2. On [DATE] at 10:46 AM MA B administered Resident #4's clonazepam (a medication used to treat anxiety) 1 hour and 46 minutes late. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to prepare and provide food and drink that was palatable, attractive, and at a safe and appetizing temperature, for 7 of 28 residents (Resident #13, #15, #17, #25, #37, #54, and #61) reviewed for palatable and appetizing food, in that: 1. The facility served Resident #25 a breakfast meal 1 hour and 2 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident. 2. The facility served Resident #13 a breakfast meal 58 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident. 3. The facility served Resident #61 a breakfast meal 56 minutes after the kitchen delivered the meal, and the meal was cold and not palatable to the resident. 4. [...]

Inspectors wroteBased on observation, interview, 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, in that: 1. The facility failed to store an opened bag of cereal in a sealed container in the dry storage room. 2. The facility failed to ensure the chlorine sanitizer in the dish machine was at the minimum concentration necessary to sanitize dishes and utensils. These deficient practices could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to honor residents' right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents, for 1 of 24 residents (Resident #24) reviewed for needs and preferences, in that: On 07/09/2024 at 11:14 AM Resident #24 was left in her bedroom, in her bed with the call light button underneath her left back. Resident #24 was semi-paralyzed on her left side and could not reach the call light button. This failure could place residents at risk for harm by not honoring residents' individualized needs and preferences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication rooms reviewed for medication storage, in that: The medication room on the second floor was left unattended and unlocked. This failure could place residents at risk for harm by not receiving the medications due to misappropriation.

Inspectors wroteBased on observation, interview and record review, the facility failed a to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #2) reviewed for disposal of garbage, in that: The facility failed to ensure Dumpster #2's door was completely shut, had a drain plug, and was free of pests. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observations, interviews, and record reviews 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 from each resident's bedside and toilet and bathing facilities, for 1 of 24 residents (Resident #25) reviewed for call light accessibility and functionality, in that: On 07/09/2024 at 01:00 PM Resident #25 utilized his call light which did not illuminate the nurse call light directly outside and above of his room door. This failurs could place residents at risk for harm by not receiving care and attention when their nurse call light system malfunctions and or is out of reach.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns, in that: The ceiling fan in the Soiled Utility Room on th 2300 Hallway had dust and dirt particles in the vent slats. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete, and accurately documented for 1 of 7 residents (Resident #3) reviewed for completeness and accuracy. The facility failed to transcribe Resident #3's order for Morphine correctly. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident for 1 of 17 (Resident #29) in that: The facility failed to honor Resident #29's right to present when Administrator A entered the resident's room and misappropriated personal items and threw them away in the trash. This failure could result in residents experiencing a decline in self-worth and quality of life.

Inspectors wroteBased on interview and record review, the facility failed to treat residents with dignity and respect of personal possessions for 1 of 17 residents (Resident #17) reviewed for resident rights, in that: Hospitality Aide D turned off, on 12/23/23 at 3:44 PM, Resident #17's electronic monitoring device, a personal possession, without asking for permission to turn off the device. This deficient practice could affect residents who reside at the facility and result in a loss of personal property, frustration and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 17 residents (Resident #29) reviewed for misappropriation and exploitation, in that: The facility did not prevent Resident #29's personal belongings from being lost when the former Administrator (A) without the resident's permission or the resident being present removed personal items from the resident's room. This failure could affect residents and their responsible party by preventing them from having access to their personal effects and belongings.

Inspectors wroteBased on observation, interview, 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 (Main Kitchen), in that: The facility failed to ensure opened items in the reach in refrigerators were dated or discarded correctly. This deficient practice could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 1 of 15 residents reviewed for call light: Resident # 214's call light was not placed within reach. This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #44) reviewed for advanced directives, in that: The facility failed to ensure Resident #44's Out-of-Hospital Do Not Resuscitate (OOH-DNR) was signed by the appropriate witnesses. This failure could place residents at-risk for residents' rights not being honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain acceptable grooming and personal hygiene for 1 of 15 residents reviewed for ADLs (activities of daily living). Resident # 54 The facility did not ensure Resident #54 received grooming for their facial hair. This failure could place residents who required assistance with activities of daily living, and who were dependent on staff to perform personal hygiene at risk for embarrassment and or decreased self-esteem or decreased quality of life.