Castle Hills Rehabilitation and Care Center

Inspectors wroteBased on record review and interview, the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility reviewed for RN coverage. The facility failed to have the services of an RN on 04/11/2026, 04/12/2026, and 05/10/2026. This failure placed the residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in clinical complications) for 2 of 8 residents (Residents #1 and #2) reviewed for resident rights. The facility failed to notify Resident #1 and Resident #2's physician when they each drank 1 [NAME] on 04/17/26. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.

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 3 of 8 residents (Residents #3, 4, and 5)) reviewed for pharmacy services. The facility failed to check Resident #3's and Resident #4's blood sugars to administer their respective insulins per doctor's orders on 05/10/26 at 6:30 AM.The facility failed to ensure Resident #5 had Methadone HCl available to her on 05/09/26 at 07:00 PM, 05/10/26 at 07:00 AM, and 05/10/26 at 07:00 PM. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that 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 2 of 5 residents (Resident #1 and #2) reviewed for care plans:1. The facility failed to ensure Resident #1's care plan reflected the resident's family members had been instructed/educated regarding the requirement that resident care be provided by facility staff rather than by family members.2. The facility failed to ensure Resident #2's care plan reflected he had been assessed to safely self-administer medications. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 1 of 5 Residents (Resident #2) reviewed for medication storage:The facility failed to ensure Resident #2 did not have a tube of Permethrin 5% cream (a topical medication used to treat scabies; a contagious skin condition caused by tiny mites that burrow into the skin) inside a drawer in the resident's vanity. This deficient practice could affect residents who received medications in the facility and place them at risk for not receiving the correct medications, medication misuse or drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Resident #2) reviewed for accuracy of records:The facility failed to ensure nursing staff documented Resident #2 had been assessed to self-administer medications. This failure could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.

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 1 of 4 residents (Resident #1) reviewed for infection control:The facility failed to ensure Resident #1's indwelling urinary catheter tubing was not touching the floor. This failure could place residents at risk of infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one 1 of one 1 kitchen reviewed for food safety requirements. The facility failed to ensure: Dishes were kept clean and dry. Food in the walk-in refrigerator was fresh and dated. Food in the walk-in freezer was dated and stored properly. Storage bins and serving utensils were clean. These failures could place residents at risk for the spread of infections, food contamination, food-borne illnesses, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, 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 2 of 2 residents (Resident #3 and Resident #5) reviewed for infection control. The facility failed to ensure: CNA A performed hand hygiene according to facility policy and followed infection control procedures while providing care for Resident #5 on 4/14/26. CNA B followed EBP and infection control procedures while providing care for Resident #3 on 4/14/26. This deficient practice could affect all residents who receive care, placing them at risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartment within 2 of 2 medication carts (nurse cart in south hall and nurse cart in north hall) observed for medication storage. Nurse cart on south hall was left unlocked and unattended in front of the nurse's station with no staff at the nurse's station. Nurse cart on north hall was left unlocked and unattended in front of a resident's room when nurse went to the nurse's station. This failure could place residents at risk of missing or misuse of drugs by unauthorized personnel.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 3 residents reviewed for assessments. Resident #1's admission MDS assessment, dated 02/03/2026, identified the resident did not have pressure ulcer. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 3 residents reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected her unhealed stage pressure ulcer to her left and right buttock area. This failure could place residents at risk for not receiving proper care and services.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) out of 3 residents reviewed for medical records. Facility nurses did not document their initials on Resident #1's treatment administration record after giving wound care to the resident on 02/01/2026, 02/07/2026, and 02/08/2026. This failure could place residents at risk for missed treatment and medications which could result in decline in healing and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (1) of seven (7) residents (Resident #1) reviewed for pharmaceutical services. RN A failed to administer Resident #1's cefazoline sodium injection solution (an antibiotic) at the rate confirmed through the pharmacy during administration on 01/15/2026. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

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 one (1) of seven (7) residents (Resident #2) reviewed for infection control. The facility failed to ensure Resident #2's foley catheter (a tube inserted into the bladder used to drain urine from the bladder) bag was not touching the floor. This failure could place residents at risk of infection and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service sanitation. The kitchen was dirty. This failure could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness. During an observation on 10/2/25 from 10:45 AM to 11:10 AM, the kitchen reflected a need for sanitation, cleanliness and safety Observation reflected: dirt, crease build-up, and debris under the juice table, pantry floor, steam table, and cooking table. During an interview on 10/2/25 at 11:00 AM, the FSS stated that he had no explanation for the dirty kitchen. The FSS added that he was up all last night trying to clean the kitchen and had no help. During an interview on 10/2/25 at 11: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed maintain all mechanical, electrical, and patient care equipment in safe operating condition 1 of 1 kitchen observed for food service sanitation and safety. The kitchen had numerous overhead ceiling lights were not functioning. This failure could place residents who eat meals from the kitchen at risk for food contamination, and food borne illness. During an observation on 10/2/25 from 10:45 AM to 11:10 AM, the kitchen reflected lack for safety, 3 ceiling lights were not functioning over the 3-sink area, 2 lights over the cooking table, and 2 lights not functioning in the pantry. During an interview on 10/2/25 at 11:00 AM, the FSS stated that he had no explanation for the overhead lights at numerous ceiling fixtures not working. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all licensed staff possessed the appropriate competencies, and skill sets necessary to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 2 of 13 nursing staff (RN A and LPN B) reviewed for competencies. The facility failed to ensure that RN A and LPN B obtained current basic life support (CPR and AED) program certifications upon hire. This failure could affect and diminish the resident's quality of life by potentially placing the residents at risk of not receiving competent and skilled care to assure resident safety and maintain the highest practicable physical, mental, and psychosocial well-being of each resident.

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 for nutrition services. The facility failed to ensure the kitchen and refrigeration areas were free from dirt and debris. The facility failed to ensure food stored in the dry storage and refrigeration areas were labeled properly with the contents and dates prepared/opened. These failures could lead to contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 dining area and 1 of 4 (Resident #1) resident's rooms reviewed for physical environment. The facility failed to ensure Resident #1's room was free from flying insects. The facility failed to ensure the communal dining area was free from flying insects. These failures could lead to contamination and/or decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that each resident received adequate supervision to prevent elopement for 1 of 15 residents (Resident#74) reviewed for accident hazards and supervision. Resident #74 eloped at night and crossed a busy 5-lane road before she was found at a bus stop by an off-duty CNA. This failure resulted in the identification of an IJ (Immediate Jeopardy) on 09/10/25. While the immediacy was removed on 09/12/25, the facility remained out of compliance at a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy and a scope of isolated due to the facility's need to monitor the implementation and effectiveness of its Plan of Removal This failure could place residents at risk for elopement, significant injury, and serious impairment or death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the menu was followed in 1 of 1 kitchen. The facility failed to follow the recipe for the main entree to ensure there was enough for residents in the dining room and failed to update a substitution on the posted menu in the dining room. This failure could place resident at risk of frustration and a decreased quality of life.

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. The facility failed to ensure dietary staff used facial hair restraints properly during meal preparation. The facility failed ensure proper hand hygiene was performed or changed gloves when touching other items that are not being used for serving or the clean serving area. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide residents the 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 (Resident #23) of 24 residents reviewed for accommodation of needs. The facility failed to have Resident #23's soft touch call pad within reach for 2-days. The soft touch pad was located on Resident #23's nightstand out of reach. This failure could place residents at risk of not being able to communicate their need for assistance and result in unmet needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the MDS assessment accurately reflected the resident's status for two residents (Resident #25 and Resident #33) of 8 residents reviewed for MDS assessments. The facility failed to ensure Resident #25's resistive to care was coded on her Quarterly MDS Assessment. The facility failed to ensure Resident #33's nutritional status was coded accurately. These deficient practices could place residents at risk of missed or inappropriate care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights 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 2 (Residents #2 and #23) of 16 residents reviewed for comprehensive care plans.1. The facility failed to ensure Resident #2's care plan included his being a smoker. 2. The facility failed to reflect Resident #23 required a soft touch pad instead of a call light in his care plan. This facility failure could place residents at risk of inappropriate care or increased safety issues.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 (Resident #23) of 24 residents reviewed for grooming. The facility failed to perform nail care for Resident #23 who was observed with long ragged fingernails. This facility failure could place residents at risk of injuries or decreased self-esteem.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure 1 medication cart (Hallway 4 medication cart) of 4 medication carts was left unlocked and unattended. LVN A did not secure hallway #4's medication cart when she went to provide a resident medication. This facility failure could place residents at risk of misappropriation of drugs or misuse.

Inspectors wroteBased on observations, interviews and record reviews, 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 2 (Residents #69 and #23) of 3 residents reviewed for incontinent care. CNA C failed to change gloves and sanitize hands between soiled and clean items when she performed incontinent care for Resident #69. 2. CNA C failed to wear a gown or change gloves and sanitize hands between soiled and clean items when she performed incontinent care for Resident #23 who was on EBP.This failure could place residents at risk of UTI's or spread of an MDRO.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their own established smoking policy for 1 of 1 resident reviewed for smoking. (Resident #2) The facility failed to ensure to complete a Resident Safe Smoking Assessment for Resident #2. This failure could place residents at risk for injury or harm.

Inspectors wroteBased on observation and interview, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility and failed to post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public for 4 of 4 days (9/9/25-9/12/25) for 1 of 1 facility, observed for postings. The survey results were behind the receptionist's desk on a shelf and the sign for the survey results was not viewable from 9/9/25-9/12/25 during the survey period. This failure could place residents, family, and visitors at risk of not knowing the results of the facility survey history.

Inspectors wroteBased on interviews and record reviews 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 (Resident #1) reviewed for Nursing Facility Specialized Services. The facility failed to ensure a request to the State Agency was submitted for Resident #1 within the 20th day timeframe so the resident could benefit from a DME customized wheelchair. This failure could place residents at risk for not receiving the benefits of the recommendations from the LIDDA.

Inspectors wroteBased on 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, were 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 and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 1 of 5 residents (Residents #1) reviewed for reporting allegations of abuse and neglect. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person- centered care of the residents that meets professional standards of quality of care within 48 hours of a resident's admission for one (Resident #1, of five residents reviewed for baseline care plans, in that: The facility failed to implement Resident #1's baseline care plan and failed to include Resident #1's current urinary tract infection and antibiotic use in the baseline care plan resulting in Resident #1's hospitilization with a diagnosis of sepsis. This deficient practice could place residents at risk of not having their individual care needs met in a timely manner or diminished quality of life, infection, and hospitalization. An IJ was identified on 04/29/25. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that residents with indwelling catheters received appropriate treatment and services for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to manage Resident #1's foley catheter by not having orders for catheter care, monitoring for signs/symptoms of infection, or monitoring the input/output, subsequently leading to hospitalization on 03/12/25 and a diagnosis of sepsis. These failures could place Residents with indwelling urinary catheters at risk of discomfort, infections, and a decreased quality of life, and hospitalization. An IJ was identified on 04/29/25. The IJ template was provided to the facility on [DATE] at 9:37 pm. [...]

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 2 of 3 residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to ensure antibiotics dispensed for Resident #1 and Resident #2 were administered by the staff member who dispensed the medication. This failure could place residents at risk of medication errors.

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 1 of 4 residents (Resident #1) reviewed for infection control, in that: 1. The facility failed to ensure CNA A changed her gloves when moving from a dirty to clean task and failed to use appropriate hand hygiene between glove changes when she provided incontinent care to Resident #1 on 09/10/2024. 2. The facility failed to ensure CNA A and CNA B wore gowns during incontinent care on 09/10/2024 for Resident #1 who had been identified as requiring enhanced barrier precautions (EBP). These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 3 of 14 residents (Residents #8, #14, and #26) whose assessments were reviewed, in that: 1. Resident #8 was a smoker, but Resident #8's annual MDS, dated [DATE], reflected the resident did not use tobacco. 2. Resident #14 was taking Plavix (Antiplatelet) for cerebral infarction, but Resident #14's annual MDS, dated [DATE], reflected the resident was taking anticoagulant. 3. Resident #26 did not take any anticoagulant, but Resident #26's annual MDS, dated [DATE], reflected the resident was taking anticoagulant. This failure could place residents at-risk for inadequate care and services due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure items stored in the reach in freezer, reach in refrigerator, dry storage, walk in refrigerator were labeled after opening. The facility failed to ensure strawberries stored in the walk-in cooler were free from mold. The facility failed to ensure food stored in the reach in refrigerator located in the kitchen were stored at or below 41 degrees. These failures could place residents at risk of food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences that would not endanger the health or safety of the residents for 1 resident 6 ( Resident # 22) reviewed for call lights. Resident #22's was in bed with the call light on the floor at the foot of the bed, out of reach for the resident. This failure could place residents at risk of achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that 1 of 4 residents (Resident #22) received treatment and care in accordance with professional standards of practice that would meet the resident's physical needs for 1 of 5 (Resident #22) residents reviewed for quality of care. Resident #22 was in a low bed with not fall mat next to the bed. This failure could place the resident at risk for injury by not following the person-centered Care Plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 resident (Residents #24) reviewed for incontinent care. While providing incontinent care on 08/22/2024 at 2:35 p.m. for Resident #24, CNA A did not return Resident #24's foreskin to the original position. This failure could place residents at-risk for infection, paraphimosis (urologic emergency in uncircumcised males) and skin break down due to improper care practices.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable, physical, mental, and psychosocial well-being for 1 of 5 (CNA A) nursing staff reviewed for competent nursing care. While providing incontinent care on 08/22/2024 at 2:35 p.m. for Resident #24, CNA A did not return Resident #24's foreskin to the original position. These failure affect residents who depend on nursing care and could place residents at risk for injury, infection, and harm.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring (monitoring for expiration dates), receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 medication carts (South unit medication aide cart). 1. South unit medication aide cart had thickened water for administering medications on 08/22/2024, and the thickened water was expired on 07/17/2024. This failure could place residents at risk for not receiving therapeutic effects of medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys, for 1 of 3 medication carts (South unit medication aide cart) reviewed for drug security and 1 of 14 residents (Resident #3) reviewed for medications at the bedside. 1. Resident #3's 0.9% sodium chloride irrigation sterile water was left unattended and unsecured on the nightstand at the resident's bedside on 08/20/2024. These failures could place residents at risk for misappropriation of property and could place residents at risk for accidents, hazards, and not receiving therapeutic effects.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide special eating equipment and utensils for residents who need them for 1 of 14 Residents (Resident #4) who were observed during meal service. The facility did not provide a built-up spoon to Resident #4 on 08/20/2024 at 12:40 PM. The meal ticket indicated Resident #4 needed to have a built-up spoon. This failure could affect residents who depended on assistive devices and infringe on the resident's dignity and feeding independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 14 residents (Resident #8) reviewed for safe and functional equipment. Resident #8's bed headboard was loosed and swinging up and down. This failure could place residents at risk for skin tears, injury, falls and discomfort during transfers.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents and supervision. The facility failed to supervise Resident #1 who eloped from the facility on 06/19/2024 and was found approximately 50 feet away from the facility at an intersection. This noncompliance was identified as past non-compliance. The past non-compliance IJ began on 06/19/2024 and ended on 06/23/2024. The facility had corrected the non-compliance before the survey began. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 3 residents (Resident #2 and #1), in that: 1. Resident #2 was able to exit the building without staff knowing on 3/15/2024; staff were unaware Resident #2 had wheeled himself to a bus stop on a city sidewalk and was gone until he was brought back by police; staff were unaware that Resident #2 had exit seeking behavior although it was in his admission paperwork. 2. Resident #1 was able to exit the building without staff knowing on 3/19/2024; staff were unaware Resident #1 had exited the building and her whereabouts are still unknown. This failure could place resident at risk of neglect resulting in elopements that could have resulted in serious injury, harm, impairment or death. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure resident has the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 3 residents (Resident #2 and #1) reviewed for neglect., in that: 1. Resident #2 was able to exit the building without staff knowing on 3/15/2024; staff were unaware Resident #2 had wheeled himself to a bus stop on a city sidewalk and was gone until he was brought back by police; staff were unaware that Resident #2 had exit seeking behavior although it was in his admission paperwork. 2. Resident #1 was able to exit the building without staff knowing on 3/19/2024; staff were unaware Resident #1 had exited the building and her whereabouts are still unknown. [...]

Inspectors wroteBased on interview and record review the facility failed to immediately consult with the resident's physician when there was a change in condition and a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 4 of 11 residents (Residents #1, #2, #3, #4), reviewed for physician notification, in that: Residents #1-#4 were administered blood pressure medications when their blood pressures were low and outside of the physician ordered parameters without physician notification prior to or after medication administration. This failure could result in decreased continuity of care, and a delay in needed treatment and services. An immediate jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 7:23 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 4 of 11 residents (Residents #1, #2, #3, #4), reviewed for significant medication errors, in that: Residents #1, #2, #3, and #4 were administered medications to lower blood pressures when their blood pressures or Pulse was already low and outside the physician ordered parameters. An immediate jeopardy (IJ) was identified on 3/15/24. The IJ template was provided to the facility on 3/15/24 at 7:23 p.m. While the IJ was removed on 3/16/24, the facility remained out of compliance at a severity level of no actual harm with the potential for more than minimal harm at a scope of pattern due to the facility's need to monitor the effectiveness of their plan of removal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to in accordance with accepted professional standards and practices, maintain medical records on each resident that are complete and accurately documented for 7 of 11 residents (Residents #1, #2, #3, #4, #5, #7, #8) reviewed for medical records, in that: Residents #1-#5's, and #7, #8's blood pressures and or vital signs were documented as the same on different shifts on the same day and on subsequent days. This failure could place residents at risk for inaccurate health assessments, medication administration errors, and could result in missed signs and symptoms of illness.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive resident centered care plan for 1 (Resident #9) of 11 residents reviewed for comprehensive resident centered care plans, in that: Resident #9's care plan was incomplete and did not accurately describe his care needs. This deficient practice could result in insufficient resident care.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's responsible party has the right to exercise the resident's rights for 1 of 9 residents (Resident #1) reviewed for resident representative rights in that: The facility failed to inform Resident #1's representative (RP) before asking Resident #1 to sign an application for Medicaid. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions.

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 9 residents (Resident #7, #8, and #9) reviewed for infection control in that: Housekeeper E did not perform hand hygiene between passing meals for Resident #7, Resident #8, and Resident #9. This deficient practice could affect all residents and place them at risk for infection.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were informed before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 (Resident #13, #198, and #199) residents reviewed for Medicare/Medicaid services. 1. Resident #13 was not given a Skilled Nursing Facility Advanced Beneficiary Notice of Non-Coverage (SNF ABN) and Notice of Medicare Non-Coverage (NOMNC) when discharged from skilled services prior to her covered days being exhausted. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior in 2 of 3 resident rooms (Rooms #128 and #129) and for 2 of 6 Resident's (Resident #1 and #28) reviewed for environment, in that: 1. The facility failed to ensure Resident #1's personal refrigeration was clean and the temperature was monitored regularly including in the resident's room. 2. The facility failed to ensure the temperature was monitored regularly for the personal refrigerator in room [ROOM NUMBER]. 3. The facility failed to ensure the fan blades did not have built up dust on them for the fan in room [ROOM NUMBER]. 4. The facility failed to ensure the torn and cracked arm rests on Resident #28's wheelchair were changed out as needed. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #37) reviewed for medications, that:. Resident #37's medication ordered for hypotension (low blood pressure) was administered when the resident's blood pressure was normal or high. This failure could place resident's at risk of medication complications.

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. 1. There was a zipper-sealed bag with four French toast sticks that did not have a label indicating a storage or use-by date. 2. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. 3. The ice machine scoop was stored inside the machine instead of in the holder affixed to the wall. These failures 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 provide comfortable environment for residents and staff for 4 of 4 (Residents #1, #19, #20 & #24), in the main dining room and in 8 of 8 resident rooms (#144, #142, #136, #133, #108, #114 and #128) in the facility reviewed for operation of the cooling system. The facility failed to maintain acceptable temperature parameters between 71 and 81 degrees for Residents #1, #19, #20 & #24, within the facility including in the main dining room and in rooms #144, #142, #136, #133, #108, #114 and #128. This deficient practice could affect any resident, make them feel uncomfortable and place residents at risk for heat exhaustion.

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 was provided for 20 of 20 employees (the Administrator, DON, AD, DM, PT, OT, ST, SW, LVN B, LVN C, LVN D, RN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, and CNA L) reviewed for training. The facility failed to ensure that quality assurance and performance improvement training was provided to the Administrator, DON, AD, DM, PT, OT, ST, SW, LVN B (ADON), LVN C, LVN D, RN E, CNA F, CNA G, CNA H, CNA I, CNA J, CNA K, and CNA L. 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 ensure that Pre-admission Screening and Resident Review (PASARR) Level 1 Resident with a positive trigger for mental illness was provided with a PASARR Level II assessment for 1 of 1 Resident (Resident #1) reviewed for mental illness. The facility failed to provide a PASARR Level II assessment for Resident #1 after PASARR Level 1 assessment revealed the Resident triggered positive for mental illness. This deficient practice could place Residents who had a positive PASARR Level 1 evaluation at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 2 of 15 Residents (Residents #28 & #34) reviewed for care plans. 1. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #28 to address the resident's nutritional problem and use of supplemental oxygen therapy. 2. The facility failed to fully develop a comprehensive person-centered care plan that was specific for Resident #34 to address the resident's use of supplemental oxygen. [...]

Inspectors wroteBased on interview and record review the facility failed to have a final summary of the resident's status at the time of the discharge that is available for release to authorized persons for 1 of 3 residents reviewed for discharge summary (Resident #46)). Resident #46 did not have a discharge summary sheet or documentation in her record. The facility failed to ensure all of Resident #46's necessary information was provided to ensure a safe and effective transition back home. This deficient practice could place any resident preparing to discharge at risk for not getting the necessary care and services to meet their physical and psychological needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for 1 of 1 resident, (Resident #28) whose records were reviewed for nebulizer and oxygen therapy. Nursing staff failed to store Resident #28's incentive spirometer device in a plastic bag after use. These deficient practices could affect any resident receiving respiratory therapy and could contribute to the development of an infection.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to dispose of garbage and refuse properly for 3 of 5 waste receptacles in that: There were three waste receptacles with their top lids completely open; of the three, two of the waste receptacles were overfilled with bags of trash past the opening of the receptacles. There was significant trash and debris in front and behind the row of waste receptacles. These failures could place residents at risk for exposure to germs and diseases carried by vermin and rodents.