Castro County Nursing & Rehabilitation

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had the right to send and receive mail for 3 of 11 confidential residents reviewed for right to communication. The facility failed to ensure residents received their mail unopened. This failure could put residents in the facility who receive mail at risk for a decline in the residents' psychosocial well-being and quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to esure prompt efforts were made to resolve grievances for 7 of 11 confidential residents reviewed for grievances. The facility failed to ensure 7 confidential residents were provided with prompt resolution for their grievances at the facility. This failure could place residents at risk of unresolved grievances and decreased quality of life and low self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that pureed food was prepared in a form designed to meet individual needs for the lunch meal on 07/22/2026. The facility failed to puree the meatballs with rice and the squash to a smooth texture. This failure could place residents at risk of swallowing difficulties, decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain and ensure safe and sanitary storage of residents' personal food items for 1 of 1 food nourishment refrigerator reviewed for food safety in that;The facility did not have a system in place to label and date perishable food in the nourishment refrigerator used by the residents to ensure safe food handling and prevent consumption of spoiled and/or expired foods. These failures could place residents at risk for food borne illnesses.

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 3 (Resident #39) residents reviewed for infection control. LVN B failed to ensure medications were administered in a sanitary manner, when LVN B dispensed Resident #39s medication into her bare hand before placing into a medication cup. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures for screening to ensure potential employees were screened before hire for 2 of 5 employees (RN A, [NAME] B) reviewed for employability status. The facility failed to ensure the Employee Misconduct Registry /Nurse Aide Registry check was conducted for RN A and [NAME] B before hire. B. The facility failed to ensure the Criminal History check was conducted for RN A before hire. This failure could place residents at risk of abuse, neglect and/or exploitation.

Inspectors wroteBased on interview and record review the facility failed to notify and provide a copy of the 30-day discharge notice to the representative of the Office of the State Long Term Care Ombudsman for 1 of 1 residents (Resident #1) reviewed for discharge planning. The facility failed to ensure notification of a 30-day discharge for Resident #1 was provided to the Ombudsman. This failure could result in residents not having adequate assistance and services in placement issues. Findings Included:Record review of Resident #1 's facility record revealed she was a 59-yo female admitted to the facility on [DATE] with diagnoses of paranoid schizophrenia, schizophrenia unspecified, delusional disorders, unspecified psychosis not due to a substance, post-traumatic stress disorder, mild cognitive impairment and diabetes. [...]

Inspectors wroteI. Investigation Visit: Based on interview and record review, the facility failed to ensure that residents were free from physical or sexual abuse for 19 (Resident #53, #56, #58, #47, #46, #49, #44, #4, #73, #32, #15, #72, #70, #71, #50, #1, #3, #41, and #14) of 19 residents reviewed for abuse/neglect. 1. The facility failed to protect Resident #41 from abuse when Resident #58 groped her on 03/27/2025. 2. The facility failed to protect an unidentified resident from abuse by Resident #58 when Resident #58 slapped the unidentified resident on 03/29/2025. 3. The facility failed to protect Resident #44 from physical abuse when Resident #44 was pushed to the floor by Resident #46 on 10/27/2024. Resident #44 fractured a hip as a result of the fall. 4. The facility failed to protect Resident #71 from physical abuse when Resident #53 smashed Resident #71's fingers with a metal cup on 01/23/2025. [...]

Inspectors wroteI. Investigation Visit Based on interview and record review, the facility failed to implement their policies and procedures that prohibited abuse for 19 (Resident #53, #56, #58, #47, #46, #49, #44, #4, #73, #32, #15, #72, #70, #71, #50, #1, #3, #41 and #14) of 19 residents reviewed for abuse/neglect. 1. The facility failed to protect Resident #41 from abuse when Resident #58 groped her on 03/27/2025. 2. The facility failed to protect an unidentified resident from abuse by Resident #58 when Resident #58 slapped the unidentified resident on 03/29/2025. 3. The facility failed to protect Resident #44 from physical abuse when Resident #44 was pushed to the floor by Resident #46 on 10/27/2024. Resident #44 fractured a hip as a result of the fall. 4. The facility failed to protect Resident #71 from physical abuse when Resident #53 smashed Resident #71's fingers with a metal cup on 01/23/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for 11 (Resident #53, #56, #58, #47,#46, #4, #73, #32, #15, #72 and #70) of 14 residents reviewed for comprehensive care plans. - The facility failed to develop and implement Resident #53's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #56's care plans to reflect the resident's aggressive behaviors. - The facility failed to develop and implement Resident #58's care plans to reflect the resident's aggressive behaviors. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 4 of 9 residents (Resident #7, #10, #15 and #41) reviewed for accidents and hazards. The facility staff failed to store hand sanitizer properly on 04/20/25 at 7:00 AM resulting in Resident #7 observing Resident #10 drinking an unknown amount of hand sanitizer which ended in him going to the hospital. The facility failed to provide adequate supervision for Resident #10 on an unknown date (after 4/20/25) in the dining room where he was able to drink the saliva of another resident (Resident #15) out of her (Resident #15) spit cup. [...]

Inspectors wroteBased on interview and record review, the facility failed to report an alleged violation of abuse or neglect immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involved abuse or result in serious bodily injury, to officials in accordance with State law, including to the State Survey Agency for 19 (Resident #53, #56, #58, #47, #46, #49, #44, #4, #73, #32, #15, #72, #70, #71, #50, #1, #3, #41 and #14) of 19 residents reviewed for abuse/neglect. 1. The facility failed to report Resident #58 groped a Resident #41 on 03/27/2025. 2. The facility failed to report Resident #58 slapped another resident on 03/29/2025. 3. The facility failed to report Resident #44 was pushed to the floor by Resident #46 and sustained a broken hip on 10/27/2024. 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, and distributed in accordance with professional standards for 1 of 1 kitchen reviewed for food safety. The facility failed to ensure foods served to residents were not laying on the kitchen countertops, open to air. The facility failed to ensure refrigerated foods served to residents were covered, labeled, and dated. The facility failed to ensure dry pantry foods served to residents were properly sealed, labeled and dated. The facility failed to ensure frozen foods served to residents were properly sealed, labeled and dated. These failures could cause residents who consumed these foods to become sick due to food-borne illness, and/or a loss a of the food's nutritional value.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the reasonable accommodation of resident needs and preferences for 3 of 15 residents (Resident #17, Resident #19, and Resident #51) reviewed for call light placement. The facility failed to ensure that Resident #17, Resident #19 and Resident #51 had access to their call lights. This failure could place residents at risk of not receiving the necessary assistance they need to maintain their highest level of independence.

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for RN coverage. The facility failed to ensure the presence of a register nurse to oversee the care for high acuity residents and the care provided by other staff such as Licensed Vocational Nurses (LVNs) and Certified Nurse's Aides (CNAs) for 30 of 31 days in January 2025, 19 of 28 days in February 2025, 20 of 31 days in March 2025, and 20 of 30 days in April 2025. This failure could place residents with unpredictable health concerns or requiring a higher level of care at risk of serious injury, harm, impairment, or death.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #7) of 15 residents reviewed for advanced directives. Resident #7 had a DNR in his record that was missing the date when Resident #7 initiated the form. The facility's failure could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable environment for 3 (Room A2, A10, and F5) of 41 resident rooms reviewed for environment. -Room A2 had a large hole in the wall between the resident's bedside dressers. -Room A10 had two large holes and one small hole in the wall between the bathroom and closet doors. -Room F5 had a large area of peeling paint at the head of a resident's bed. These failures could place residents at risk for diminished quality of life due to the lack of a well-kept environment.

Inspectors wroteBased on interview and record review, the facility failed to establish and follow a written policy on permitting residents to return to the facility after being hospitalized for 1 resident (Resident #73) of 19 residents reviewed for transfer/discharge. The facility did not allow Resident #73 to return to the facility after evaluation and treatment at a Psych Hospital. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility causing a disruption in their care and services and potential decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care, was provided consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 2 (Resident #9, #27) of 15 residents reviewed for respiratory care. The facility failed to ensure Resident #'9's and #27's oxygen setting was per physician orders. This failure could affect residents by placing them at risk for respiratory compromise and associated complications such as shortness of breath, confusion, respiratory failure, infection, and exacerbation of their condition. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 15 residents (Resident # 38) reviewed for trauma-informed care. The facility did not ensure Resident #38 had a trauma screening that identified possible triggers when Resident #38 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices for each resident that are complete, accurately documented, readily accessible, and systemically organized for 2 (Resident #31, 42) of 15 residents reviewed for medical records. The facility failed to ensure Resident #31's and Resident #42's physician orders and care plans reflected their current status of no longer being in the secured unit. This failure could place residents at risk of having records that do not reflect their current status or needs. Findings Included: [...]

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 1 (Resident #27)) of 4 residents observed for infection control. -CNA C did not wash her hands while performing incontinent care for Resident #27. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections, tissue breakdown, and feelings of isolation related to poor hygiene.

Inspectors wroteBased on observations and interviews, the facility failed to ensure corridors were equipped with firmly secured handrails on each side for 1 (A Hall) of 6 halls reviewed for handrails. The handrail between room A8 and A10 was loose. This deficient practice has the potential to place residents at risk for injuries related to falls that could result in bruising, skin tears, wounds, fractures, and decreased quality of life.

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 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 and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address Resident #1's bipolar disorder, anxiety and depression and their interventions. This failure could place residents at risk of not receiving desired and necessary care and treatment. Findings Included: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for one of five (Resident #1) residents reviewed for medication administration. -Resident #1 received a dose of 100units of insulin glargine instead of the prescribed 11units on the evening of 02/16/2025 in error. This failure could place residents who receive insulin medications at an increased risk for complications such as decreased blood glucose levels, change in cognition, and an exacerbation of symptoms and disease process. The noncompliance was found to be Past Non-Compliance (PNC). The noncompliance began on 02/16/2025 and ended on 02/17/2025. The facility corrected the noncompliance before the investigation began.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications and a decision to transfer or discharge the resident from the facility for 1 (Resident #1) of 5 residents reviewed for notification. LVN D failed to notify Resident #1's family and physician when Resident #1 was found unresponsive in his room and sent to the hospital via ambulance. This failure could cause residents to feel alone and/or abandoned by their family members in times of crisis. Findings Included: [...]

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of resident and misappropriation of resident property for 1 (Resident #1) of 5 residents reviewed for abuse. The facility failed to implement their policy titled Abuse, Neglect and Exploitation when CNA A failed to report bruising to Resident #1's ribcage she found on 01/24/25 during a brief change. This failure could place residents at risk of abuse/continued abuse. Findings Included: [...]

Inspectors wroteBased on interviews and record reviews the facility failed, in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #1) of 5 residents reviewed for accuracy of medical records. The facility failed to list the correct behavioral hospital on Resident #1s admission Record. The facility failed to perform a skin assessment on Resident #1 for three days (01/18/25, 01/19/25, and 01/20/25) following his admission skin assessment, as per their Skin Assessment policy. The facility's failure to ensure medical records on each resident were complete, accurately documented, and readily accessible, placed all residents requiring care at risk for incorrect or omitted treatment, duplicated treatments, and a failure to ensure continuity of care. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for 1 of 1 kitchen staff (Dietary Manager) reviewed for qualifications. The Dietary Manager failed to have the appropriate license, certification, or qualifications to function as the Director of Food and Nutrition Services. This failure could place residents who consume food prepared from the kitchen at increased risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on interview and record review, the facility failed to send a copy of the discharge notice to the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 5residents reviewed for transfer/discharge. The facility failed to provide a notice of discharge to the facility's Ombudsman as soon as practicable when Resident #1 was discharged on 12/11/24 to a locked unit at another facility due to the current facility not being able to meet Resident #1's needs. This failure could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States for 11 (Resident #2, Resident # 3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) of 54 residents reviewed for resident rights. The facility failed to ensure 11 residents (Resident #2, Resident # 3, Resident #5, Resident #6, Resident #7, Resident #8, Resident #9, Resident #10, Resident #11, Resident #12, and Resident #13) were able to vote in the election of 2024. This failure could place residents at risk of feeling unheard and devalued. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 2 (Resident #1 and Resident #4) of 6 residents and 3 (Room A2, Room A7, and Room A9) of 8 rooms on the locked unit reviewed for environment. 1. The facility failed to ensure Resident #1 had a sink in his bathroom for approximately a week. 2. The facility failed to ensure Resident #4 had a sink in her bathroom for an undetermined period of time. 3. The facility failed to ensure the sinks in the bathrooms of Room A2, Room A7, and Room A9 were securely attached to the wall. These failures could place residents at risk of injury, infection, and feeling ill at ease in their living environment. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review 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 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 (Resident #1) of 6 residents reviewed for abuse and neglect. [...]

Inspectors wroteBased on interviews and record review; it was determined the facility failed to ensure that in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete, accurately documented, and readily accessible for 1 of 6 residents reviewed for clinical records (Resident #1) in that: The facility failed to ensure Resident #1's concerns about the prior administrator were documented and addressed in social services notes. The facility's failure to ensure medical records on each resident were complete, accurately documented, and readily accessible, placed all residents requiring care at risk for incorrect or omitted treatment, duplicated treatments, poor self-esteem and self-worth, and a failure to ensure continuity of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 7 (Resident #1) residents reviewed for PASRR. The facility contacted the HHSC PASRR Unit on 5-7-2024 for Resident #1 and no NFSS (Nursing Facility Specialized Services) form was provided to the HHSC PASRR Unit by the required date of 5-10-2024. This failure could affect residents with mental illnesses and placed them at risk of not being assessed to receive needed services.

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 in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food was properly labeled and dated. This failure could put place Residents at risk for foodborne illness. Findings Included: Observation of shelved/refrigerated foods on 4/7/2024 at am revealed the following: 1. Observation of freezer 1 on 4/7/24 at 9:16 am revealed 1 bag of meat with no label or date. 2. Observation of freezer 1 on 4/7/24 at 9:18 am revealed 1 bag of squash in a plastic bag with no label or date. 3. Observation of freezer 1 on 4/7/24 at 9:18 am revealed 1 bag of green beans with no label or date. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a comfortable environment for 4 of 10 anonymous residents reviewed for environment and a homelike environment for 9 (Resident #2, #4, #21, #22, #27, #34, #36, #41, and #96) of 19 residents reviewed for environment. The facility failed to ensure during dining times that residents had comfortable sound levels that encouraged interactions. The facility failed to provide any furnishings to promote a homelike environment for 9 residents residing in the locked unit. This failure could place residents at risk for increased stress and affecting residents overall wellbeing. This failure could place residents 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 ensure medications were stored in accordance with currently accepted professional principles for 1 (the medication room) of 2 medication storage areas reviewed for medication storage. The medication room refrigerator had medications that had been stored out of recommended storage temperatures. The facility's failure to ensure medications were stored in accordance with currently accepted professional principles could result in a resident receiving the incorrect medication or a medication that would be ineffective for their treatment resulting in exacerbation of the resident's condition and disease processes.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all residents had the right to formulate an advanced directive for 1 (Resident #21) of 13 residents reviewed for advanced directives. Resident #21 had a DNR in his record that was missing information in the Two Witness's Section. The facility's failure to ensure the accuracy of a residents advanced directive such as a DNR (Do Not Resuscitate), recognized under State law (whether statutory or as recognized by the courts of the State), relating to the provision of health care could place residents a risk for not receiving healthcare as per their or their legal representatives wishes.

Inspectors wroteBased on interview, and record review the facility failed to conduct a comprehensive and accurate assessment of each resident using the resident assessment instrument (RAI) specified by CMS for 1 (Resident #40) of 13 residents whose records were reviewed for assessments. Resident #40 was not listed as using tobacco on his 11-14-2023 admission MDS. This failure to ensure comprehensive and accurate assessments could affect residents by placing them at risk for inaccurate and incomplete MDS assessment which could result in residents not receiving correct care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 12 residents (Resident # 23) reviewed for activities of daily living. The facility failed to assess Resident # 23's needs for a communication board to assist her to effectively communicate with staff. This failure could place residents at risk of not receiving services/care and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 2 of 12 residents (Resident #33 and Resident #40) reviewed for accidents and hazards. 1. The facility failed to ensure that a space heater was not being utilized in Resident #33's room. 2. The facility failed to ensure that Resident #33 did not have a lighter in his room. 3. The facility failed to ensure that Resident #40 did not have a Vape pen in his room. This failure could affect residents at the facility by placing them at risk for fire related injuries or ingesting unknown liquids from the Vape Pen.

Inspectors wroteBased on interviews, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 (02/11/2024) of the last 90 days reviewed. The facility did not have an RN working in the facility for 1 (02/11/2024) of the last 90 days reviewed. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for coordination of events such as hospice care, emergency care and disasters such as with flooding, power outage, tornado, fire, etc.

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents for 1 of 5 staff (LVN A) reviewed for abuse policies. The facility failed to implement their own written policy and procedure for screening by not completing a Criminal Background Check for LVN A until 1/11/2024, 8 days after her hire date on 1/3/2024. This failure could place residents in the facility at risk of Abuse, Neglect, or Exploitation.

Inspectors wroteBased on observation, interview, and record review the facility failed to distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 dining rooms reviewed for dining room sanitation. The facility failed to ensure proper hand hygiene was practiced during the distribution and service of resident food trays. These failures could place residents at risk for transmission-based illness.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for 5 of 5 (CNA D, CNA E, LVN Charge, LVN B and BOM (Business Office Manager) newly hired staff reviewed for nursing home training. The facility failed to ensure new employees were properly trained in the prevention of Resident Abuse, Neglect and Exploitation, HIV Policy and Procedures, Fall Prevention, Restraints, Emergency Procedures and Dementia. This failure could place residents at risk for a diminished quality of life and diminished psycho-social well-being, due to lack of training in essential Resident Care and Facility Practice.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess residents for risk of entrapment from bed rails prior to installation for 1 of 11 (Resident #1) residents reviewed for bed rails. The facility failed to ensure Resident #1 had (1) one-half bed rail, on the right side of his bed with no documentation of physician orders, consent, or safety assessment prior to installation. This failure could place residents at risk of injury, hinder residents from getting out of bed, and/or cause a decline in resident's ability to engage in activities of daily living.

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 1 facility reviewed for infection control. The facility failed to properly dispose of an insulin syringe and maintain a clean environment free of bloodborne pathogens. This failure could place residents at risk of communicable diseases, decline in health and mental status, and cause potential harm that may lead to injury.

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 environment. The facility failed to properly clean resident's rooms, maintain safe structure of the ceiling, provide a clean dining area, and ensure working order of sinks in the facility. This failure could place residents at risk of psychosocial decline, an increased institutional character setting, and spread of infections which could result in a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Flies were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections.

Inspectors wroteBased on observation, interview, and record review 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 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 (Resident #1) of 5 residents reviewed for abuse and neglect. [...]