Burleson Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review the facility did not provide drugs and related services needed by each resident for 1of 1 medication storage rooms and 1 of 3 medication carts (Medication Cart A) reviewed for medication storage. The facility failed to ensure:- expired medication administration supplies was removed from the medication storage room- opened resident medications was dated on the date they were opened. This failure could place residents at risk for ineffective treatments, infections, or not receiving the therapeutic benefit of the medication. Observation on 9/22/25 at 2:45 PM of the E Hall Nurse medication cart revealed the following medications were opened for use and did not have a date indicating when they were opened: 1 Albuterol 90 MCG Inhalers opened and not dated. 1 Albuterol 90 MCG Inhalers opened and not dated. [...]

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 storage, food safety, and nutrition services for 1 of 1 kitchen. The facility failed to ensure food items were labeled and/or dated. This failure could place residents at risk of foodborne illness by being served expired food. Findings Included: Observation on 9/21/2025 at 9:13 AM of the cooler revealed the following:1 sheet cake prepared in the pan sitting on top of boxes uncovered and not dated.1 bag of shredded lettuce sitting on a shelf open and undated. In an interview on 9/21/2025 at 9:13 AM, the DM stated the sheet cake was just cooked this morning, and the staff had placed it in the freezer to cool down and the bag of lettuce was just opened. The DM stated the staff forgot to place a date on it. [...]

Inspectors wroteBased on interview and record review, the facility admitted an individual with a positive PL1 without a complete PE and PASRR determination for 1 of 12 residents (Resident #1) reviewed for PASARR services. The facility failed to ensure a PASARR screening was completed correctly for Resident #1. Resident #1 was marked No for mental illness. This deficient practice could place residents at risk for not obtaining the services needed to treat their mental health diagnoses.

Inspectors wroteBased on interview and record review, the facility failed to complete a comprehensive assessment within 14 calendar days after admission as required for 1 (Resident #1) of 5 residents records reviewed for comprehensive assessments and timing. The facility failed to ensure Resident #1 did not have a completed admission/comprehensive MDS assessment within 14 days following his admission to the facility. This deficient practice could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with an indwelling urinary catheter received treatment and services for 1 of 5 residents (Resident #1) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #1's urinary drainage bag tubing and bag were kept from touching and resting on the floor. This deficient practice could affect any resident with an indwelling urinary catheter and place them at risk of developing or increased UTIs.

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 6 residents (Residents #1) reviewed for resident rights in that: The facility failed to ensure Residents #1's call light was within reach on 12/11/24. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections 1 of 1 facility reviewed for infection control. The facility failed to clean and disinfect soiled shower chair in combined shower room A and B. The facility failed to clean and discard soiled wipes left on the floor in shower room C. This failure could place resident at risk of infection transmission.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for the facility's only kitchen reviewed for accidents and hazards. The facility failed to take temperatures of soup during meal service, which resulted with soup being served at 180 degrees. This failure could have placed residents at risk of being burned.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safely for 3 of 11 residents (Resident #2, Resident #4, and Resident #5) reviewed for dietary services. The facility failed to ensure staff cleaned, or sanitized, their hands prior to meal service delivery. This failure could have placed residents at risk of the spread of infection.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe and sanitary environment to help prevent the development and transmission of communicable diseases and infections 1 of 1 facility reviewed for infection control. 1. The facility failed to keep stored linens covered. 2. The facility failed to follow EBP (Enhanced Barrier Precaution was an infection control intervention designed to reduce transmission of MDRO that employed targeted gown and glove use during high contact resident care activity) while having provided direct care for Resident #12. This failure could place resident at risk of infection transmission.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to 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 for 4 of 62 residents (Resident #1, Resident #2, Resident #6, and Resident #10) reviewed for accommodation of needs. The facility failed to ensure the BCLB, in Resident #1, Resident #2, Resident #6, and Resident #10's was fully accessible for its intended use. This failure could have placed residents at risk of having their needs gone unmet. Findings Included: Resident #1 Record review of Resident #1's FS, downloaded from the Matrix on 10/4/2024, reflected a [AGE] year-old woman, born on 5/10/1951, who's admittance date to the facility was on 7/16/2024. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for the 1 of 15 residents (Resident #12) reviewed for a safe and comfortable environment. The facility failed to report maintenance issues to the MNTD and make repairs to a broken toilet seat in Resident #1's bathroom. This failure could have placed the residents at risk of falling from skin breakdown or falling from the toilet. Findings Included: Record review of Resident #1's FS, downloaded from the Matrix on 10/4/2024, reflected a 73 year/old woman, born on 5/10/1951, who's admittance date to the facility was on 7/16/2024. She was diagnosed with dementia (which was a disease that affected memory, thought, and interfered with daily life.) Record review of Resident #1's admission MDS, dated [DATE], reflected the resident had a BIMS Score of 9. [...]

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 reviewed, in that: The facility failed to ensure that the cucumbers in the facility's refrigerator, were placed in a sealed container according to guidelines. The facility failed to ensure that the dented cans were removed and separated from the other canned food. The facility failed to ensure that the dust on the air filters and air vents in the kitchen were cleaned. These deficient practices could affect residents who received meals and/or snacks from the main kitchen and place them at risk for cross contamination and other air-borne illnesses. Findings Included: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for 1 of 8 residents (Resident #18) reviewed for self-determination. The facility failed to ensure Resident #18 received a bed bath as scheduled and upon request and failed to assist her out of bed when she requested to attend a Resident Council meeting. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal hygiene for 1 of 8 residents (Resident #18) reviewed for ADLs. The facility failed to ensure Resident #18 received a bed bath as scheduled and upon request and failed to assist her out of bed when she requested to attend a Resident Council meeting. This failure could place residents at risk for being denied the opportunity to exercise his or her autonomy regarding things that are import in their life and decrease their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 1 (Hall B) of 6 halls, 1 of 1 nurses' station and 1 of 1 dining room. The facility failed to ensure Hall B, nurses' station and the dining room were free from flies. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated 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 for two (Residents #4 and Residents #44) of five residents reviewed for dignity. The facility failed to promote both Resident #4 and Resident #44's dignity by not covering their catheter urinary collection bag with a privacy bag. This failure could place residents with catheters at risk for a loss of dignity, decreased self-worth and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 2 residents (Resident #20) reviewed for tube feeding. LVN A failed to check placement of Resident #20's g-tube (a tube going into the stomach through the abdomen to administer medications and liquid nutrition) placement prior to flushing with water and administered bolus feeding. LVN A did not flush g-tube with the correct amount of water before and after bolus feeding. Facility failed to follow physician order for Resident #20 when cleaning enteral stoma site by not applying gauze dressing. This deficient practice could place residents who require enteral feedings at risk for weight loss, dehydration, metabolic abnormalities, and hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 (C Hall cart) of three nurse medication carts reviewed for medication storage. LVN A failed to remove expired medications for Resident #14 from the nurse medication cart for the C Hall cart. This failure placed residents at risk of receiving medications that failed to deliver their full effectiveness.