Center at Zaragoza, LLC

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 4 residents (Resident #3) reviewed and 1 of 1 oxygen storage room reviewed for respiratory care. 1. The facility failed to check Resident #3's portable oxygen tank to ensure the oxygen tank was full when preparations were made to discharge the resident home on [DATE] to administered oxygen continuous at 2 L/min via nasal cannula. 2. The facility failed to ensure 21 oxygen metal cylinders, stored in the main oxygen storage room, were properly stored. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right and the facility made prompt efforts to resolve resident grievances the resident may have for 1 of 4 residents (Resident #1) reviewed for grievances . The facility failed to follow their policy and procedure on Grievance/Complaints when Resident #1's family member voiced a concern on 02/19/26 to Human Resources regarding a concern about the oxygen tank not working when the resident was sent to a physician's appointments on 02/19/26 and concerned that the resident was not provided catheter care. This failure could place residents at risk of feeling their voices were not being heard or taken seriously and could cause feelings of worthlessness.

Inspectors wroteBased on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #2) reviewed for quality of care .The facility failed to ensure RN D wrote the verbal order given by the Nurse Practitioner on 05/08/26 for Resident #2 for a UA with Culture & Sensitivity. This failure could place residents at risk of delayed treatment/intervention and decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses have specific competencies, and skill sets necessary to care for residents' needs, as identified through resident assessment for 1 of 6 residents (Resident #1) reviewed for nursing services.-The facility failed to ensure on 03/06/2026 that LVN A did not practice outside her scope of practice when she removed a PICC Line for Resident #1 when this needed to be completed by an RN, per Texas Board of Nursing standards. This failure placed the resident at risk for potential harm by nursing staff providing care outside of their scope of practice.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for physician notification of changes. LVN A failed to immediately notify Resident #1's physician when Resident #1 showed a change in condition (blood in urine) on 08/01/2025. These failures could place residents at risk of a delay in treatment, decline in physical, mental, and/or psychosocial status.

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 to help prevent the development and transmission of communicable disease and infections for one (Resident #1) of three residents reviewed for infection control in that:CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident # 3, Resident # 38, Resident # 104) of 12 residents reviewed for accommodation of needs. The facility failed to ensure Residents 3, 38 and 104, had their call lights within reach. These failures could place residents at risk for not having their needs/preferences met.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ADL care for 2 of 16 residents (Resident # 152 and #206) reviewed for ADLs. The facility failed to ensure Resident #152 and #206's fingernails were clean and free from debris. This failure could place residents who required assistance with ADL's at risk for unmet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for 2 (Resident #3 and Resident #155) of 12 residents reviewed for medication storage , in that: Resident #3 had a clear measuring cup at bedside with Zinc Oxide pomade (skin ointment) and a tongue depressor in it, exposed and within reach of other residents. Resident #155 had a clear measuring cup with unknown pink ointment at bedside, exposed and within reach of other residents. This failure could place residents at risk of access to medications not approved for administration by their physician.

Inspectors wroteBased on observations, interviews, and record reviews, 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 and food storage. -The facility failed to store foods in walk-in refrigerator and freezer in sealed containers. -The facility failed to label and date frozen pastries stored in the freezer. -The facility failed to keep container of tomato sauce free of dry drippings and residue around the lid. These failures could place residents at risk of food-borne illnesses.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 1 (Resident #108) of 9 residents observed for oxygen management. The facility failed to post an Oxygen sign indicating Resident # 108 received oxygen. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health and at risk of fire hazards by not posting oxygen signs outside the residents' rooms. Findings Include: Record review of Resident #108's Face sheet dated 6/18/25 revealed a [AGE] year-old female with an admission date of 6/3/25. Record review of Resident #108's admission MDS dated [DATE] revealed BIMS score of 13 indicating the resident was cognitively intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #213) of 10 residents reviewed for medications. The facility failed to administer Megestrol Acetate for Resident #213 per physician's order for 2 days. This failure could place the residents at risk of not receiving therapeutic doses of their medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 7 residents (Resident #2) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #2's use of bed rails (enablers). The facility failed to implement a comprehensive person-centered care plan for CNA B not being able to work with Resident #2 due to an facility self-reported incident. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the patient for risk of entrapment from an enabler (bed rail) prior to installation or review the risks prior to installation for 1 (Resident #2) of 4 patients reviewed for enablers (bed rails). Resident #2 did not have a Bed Transfer Bar Evaluation Assessment done to ensure the Enablers (bed rails) were appropriate for the use of Resident #2's needs. This failure could place residents who have bed [NAME] (enablers) at risk of having inappropriate or unnecessary enablers in place increasing their risk of injury.

Inspectors wroteBased on observation, interview and record review the facility failed to respect a resident's right to personal privacy during personal care for 2 of 7 residents (Resident #4 and Resident #8) reviewed for respect and dignity. Staff Coordinator did not close the room binds when providing patient care for Resident #4 during weighing Resident #4. CNA A left Resident #8's room leaving the door open exposing Patient #8's brief and private area. These failures could place residents at risk of diminished quality of life, lack of privacy, and lack of dignity.

Inspectors wroteBased on interview and record review the facility failed to ensure that the assessment accurately reflected the patient's status for 1 (Resident #2) of 4 residents reviewed for accuracy of MDS assessment. Resident #2's admission MDS did not accurately reflect the patients' use of bed rails (enablers). This deficient practice could place residents at risk of not receiving adequate care.

Inspectors wroteBased on the observation, interview, and record review the facility failed to ensure that the patients environment remains free of accidents hazards as is possible and each patient received adequate supervision to prevent accidents for 1 (Resident #4) of 4 residents reviewed for accidents. Staff Coordinator was weighing Resident #4 in her room by using a mechanical lift to lift Resident #4 by himself. Staff Coordinator did not lock the mechanical lift brakes when lifting Patient #4 up in the air as he was weighing and then moved the mechanical lift upwards to re-position Patient #4. This failure could affect residents who required the use of a mechanical lift for transfers, by placing them at risk of improper transfers resulting in injury.

Inspectors wroteBased on observation, interview, and record review it was determined the facility failed to ensure patients who were incontinent received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #3) of 2 residents reviewed for incontinent care/Foley catheter care. The facility failed to empty Resident #3's catheter before it got full backing up into the tubing. These failures placed residents at risk for infection and hospitalization.

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 safety for 1 of 1 kitchen reviewed for dietary services. A. Food containers had accumulations of dried drippings and residue on them. B. Food preparation areas had items with accumulation of dust, encrusted grease deposits, and other soiled accumulations. C. Food in refrigerator with expired dates. D. Bananas were stored next to a dirty trash bin. E. The Dietary Manager entered the kitchen without a beard guard. This failure places residents who eat food prepared by the facility at risk of food borne illnesses.

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 resident that meet professional standards of quality care for three (Resident #35, Resident #89 and #192) of 12 residents reviewed for baseline care plans. The facility failed to ensure that Resident #35 ' s baseline care plan included her expressed preference for a vegetarian diet. The facility failed to ensure that Resident #89 ' s Baseline Care Plan addressed her Diabetes II. The facility failed to ensure that Resident #192 ' s baseline care plan included pressure reducing boots and that a copy was given to the resident and the resident ' s representative. [...]

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 3 of 16 residents (Resident #11, Resident #35 and Resident #89) reviewed for Comprehensive Care Plans. The facility failed to ensure that Resident #11 ' s Comprehensive care plan addressed her Tracheostomy (a surgical opening in the throat to allow for breathing). The facility failed to ensure that Resident #35 ' s Comprehensive Care Plan addressed her preference for a vegetarian diet. The facility failed to ensure that Resident #89 ' s Comprehensive Care Plan addressed her Diabetes II. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #35) of 12 residents reviewed for quality of care. The facility failed to ensure that Resident #35 received care for a wound to her left inner knee from 03/30/2024 to 04/09/2024. This failure could result in residents not receiving care needed for wounds.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #91) of 6 residents reviewed for appropriate treatment and services to prevent complications of enteral feeding. The facility failed to ensure Resident #91 ' s enteral feeding formula bag was labeled with her name, type of feeding, frequency, time and date administration started. This failure could put residents at increased risk of receiving incorrect feeding formula and/or incorrect quantity of formula.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident was screened for a mental disorder or intellectual disability prior to admission for 10 of 16 residents (Resident #'s 48,29,47,19,44,5,32,211,55,and 11) reviewed for PASRR compliance. The facility failed to ensure that an initial PASSR screening (Level 1 screen) was completed prior to admission to the facility for Resident #'s 48,29,47,19,44,5,32,211,55 and 11. These failures could place residents at risk of not receiving specialized and/or habilitation services as needed to meet their needs

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 1 resident (Resident #51) of 4 reviewed for medication administration and failed to keep drug records to account of all controlled drugs to be maintained and periodically reconciled for 2 of 4 ( 200 hall North and South) narcotic count sheets reviewed for controlled medications in that: The facility failed to ensure: -LVN D administered Resident #51 medication through feeding tube without checking for residuals first. -LVN E signed narcotic sheet before doing end of shift narcotic count for 200 Southside Hall. -Narcotic count sheet on 200 Northside Hall was missing signatures from staff for three days. [...]

Inspectors wroteBased on the observations, interviews, 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 Food and nutrition services, in that: 1. Foods in containers and or zip lock bags in dry storage, walk in, and freezer not dated or labeled properly. 2. Stove food catchers/food traps not being cleaned regularly as there was grease built up and food pieces. 3. Therapist and Maintenance staff not wearing hair nets. 4. Sanitation logs and buckets checks are not being documented on logs to ensure the sanitation liquid was in the appropriate parts per million and sanitation cleaning duties of equipment are being done. 5. Daily Scheduled logs not being followed to ensure sanitation of kitchen equipment and labeling/ rotation of foods. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 2 of 24 residents (Resident #162 and Resident #1) reviewed for infection control in that: 1. PPE (Protective equipment such as gowns and gloves) were not disposed of properly for Resident #162. 2. Resident #1's tube feeding was not properly capped. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to properly execute the grievance process including review in morning meeting with IDT members, coordinating and developing a plan for resolution, notify complainant about resolution and document all action taken in grievance form and disposition of the grievance will be provided in writing to Executive Director or Designee for 2 out of 24 residents (Resident #20 and Resident #55) reviewed for grievances. The facility failed to document all actions taken for the resolution of grievance to included Administrator's signature in the section resolution of concern for the grievance. The facility failed to fill and resolve grievance for Resident #55's laundry not being washed . This failure could place residents in the facility at risk of grievances going unresolved.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #41) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #41's history of refusing showers. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents are given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) for 1 of 6 residents (Resident #41) reviewed for hygiene. A. Resident #41 appeared disheveled, had long fingernails, hair was not combed and greasy, he was not shaved, and had body odor. This deficient practice could place residents who required assistance with showering and maintaining good personal hygiene at risk for not receiving care and services to meet their needs and avoid ADL decline.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 6 residents (Resident #19) reviewed for foot care. The facility failed to provide access to podiatrist for Resident #19. This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that resident was free of any significant medication errors for 1 resident (Resident #51) of 4 reviewed for medication administration in that: -Blood pressure medication was not administered according to prescribed parameters for Resident #51. This deficient practice could cause a decline in health of residents who receive medication that are not according to physician orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the following information on a daily basis: (1) Facility name. (2) Current date. (3) The total number and the actual hours worked by Register Nurses, Licensed Vocational Nurses, Certified nurse's aides and Resident census at the beginning of each shift in a prominent place readily accessible to residents and visitors. The facility did not post and maintain the required staffing information from March 10, 2023 to March 13, 2023. This failure could place residents and visitors at risk of not knowing how many nursing staff were on duty and the actual hours worked per shift daily.

Inspectors wroteBased on the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (Dumpster #1 and #2) reviewed for food safety requirements. 1. Dumpsters #1 and #2 located at the back of the facility had trash on the ground outside and around the dumpsters. 2. One dumpster was to the left of the fryer oil container was uncovered. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility placing the residents at risk of illnesses, and living in an unsafe, unsanitary, and uncomfortable environment.