Chulio Hills Health and Rehab

Inspectors wroteBased on observations, staff and family interviews, record review, and review of the facility's policies titled, Notification of Changes, Change in Resident's Condition or Status, the facility's Senior Medical Systems Protocols, and New Facility Procedure, the facility failed to ensure timely physician and responsible party notification regarding a significant change in condition of resident (R) (R3) who had a decline in condition. Harm was identified to have occurred on 2/19/2026 when R3 was hospitalized due to a fall after a decline in condition.

Inspectors wroteBased on observations, staff and family interviews, record review, and review of the facility's policies titled, Notification of Changes, Change in Resident's Condition or Status, the facility's Senior Medical Systems Protocols, and New Facility Procedure, the facility failed to ensure timely assessment, monitoring, escalation, and clinical management of a resident (R) (R3) who exhibited a progressive change in condition. Harm was identified to have occurred on [DATE], when R3 was hospitalized due to a fall after a decline in condition.

Inspectors wroteBased on staff interviews, record review, and review of the facility's policy titled Abuse, Neglect and Exploitation, the facility failed to ensure a resident (R) (R2) remained free from sexual abuse.

Inspectors wroteBased on observations, staff interviews, and review of the facility's policy titled, Cleaning and Disinfection of Environmental Surface, the facility failed to provide a safe, functional, sanitary, and comfortable environment throughout the facility on the 100, 200, and 300 Halls, the common area near the nurse station, and lobby, related to delay in repairing damaged ceilings tiles and dust-like vents.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policies titled Notification of Changes and Change in a Resident's Condition or Status, the facility failed to notify the responsible party and the Registered Dietician for one of 42 sampled residents (R)(R70) of significant changes in the resident's condition. This deficient practice had the potential to compromise the resident's nutritional management, overall care, and the responsible party's ability to participate in care planning and decision-making.

Inspectors wroteBased on record review, staff interviews, review of the Resident Assessment Instrument (RAI) Manual, and review of the facility policy titled Maintaining Minimum Data Set (MDS) Assessments, the facility failed to accurately complete the Quarterly MDS assessment by not including hospice services for one of twelve residents (R) (R7) on hospice.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled Comprehensive Care Plan, the facility failed to develop and implement comprehensive, person-centered care plan for one of 42 sampled residents (R) (R47). Specifically, the facility failed to develop and implement care plan interventions related to oxygen (O2) administration. This deficient practice had the potential to place the resident at risk for inadequate monitoring and improper oxygen administration, which could compromise the resident's health and safety.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Wound Management Program Pressure Ulcers, the facility failed to ensure that appropriate pressure ulcer prevention interventions were initiated, implemented, monitored, and documented for one of 15 residents (R) (R96) who were identified as being at risk for pressure injuries and who developed a pressure ulcer during the facility stay. This deficient practice had the potential to cause actual harm, including the development and worsening of pressure ulcers, delayed wound healing, increased risk for infection, pain, and decline in skin integrity.

Inspectors wroteBased on observations, staff interview, record review, and a review of facility policy titled, Oxygen Concentrator, the facility failed to ensure that one resident (R) R89 was administered oxygen therapy in accordance with the physician's orders.

Inspectors wroteBased on observations, staff interviews, a review of the facility policy titled, Specific Medication Administration Procedures, and a review of the manufacturer's instructions for steroid inhalers, the facility failed to maintain a medication error rate below five percent. An observed medication error rate of 5.71% was identified during 35 medication administration opportunities. Specifically, medication administration errors were observed during two of five medication passes, in which nursing staff failed to instruct residents to rinse and spit after administration of corticosteroid inhalers. This deficient practice has the potential to increase the risk of medication-related side effects.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility's policy titled, Adaptive Equipment the facility failed to ensure one of eight residents (R) (R88) received a feeding adaptive equipment device at each meal. This failure had the potential to affect the nutritional independence of R88.

Inspectors wroteBased on observations, staff and resident interviews, record review, and review of the facility policies titled Infection Prevention and Control Program, and Handwashing/Hand Hygiene, the facility failed to maintain appropriate infection control practices. Specifically, a nurse was observed using a box of gloves during wound care and removing it from the resident's room for use with other residents, a staff member failed to adhere to Transmission-Based Precautions by not wearing appropriate PPE (Personal Protective Equipment) and did not perform hand hygiene when entering/exiting an isolation room, and the facility failed to ensure the Infection Prevention and Control Program policy was reviewed and updated annually. These failures had the potential to contribute to the transmission of infectious organisms among residents, staff, and visitors

Inspectors wroteBased on staff interviews, record review, and a review of the facility policy titled, Resident Trust Fund Accounting Policies and Procedures, the facility failed to maintain a Surety Bond in an adequate amount to cover the resident trust fund account balance for three of six months reviewed. This deficient practice had the potential to adversely affect the finances of 62 of 62 residents with trust fund accounts managed by the facility.

Inspectors wroteBased on staff interviews and review of the facility policy titled, Management/Dietary Services Manager, the facility failed to ensure that the staff designated as Dietary Manager (DM) was certified in dietary or food service management or had a similar food service management certification or degree. The facility census was 77 with 71 residents receiving an oral diet.

Inspectors wroteBased on observations, staff interviews, and review of facility policies titled, Food Brought by Visitors and Food Storage Guidelines, the facility failed to ensure dietary staff labeled and dated open food items in the dry storage area; failed to prevent/remove ice build-up on top of opened food to prevent contamination in the walk-in freezer; failed to label and date resident foods items the resident nourishment room and; failed to demonstrate the proper procedure to sanitize dishware in the three compartment sink to prevent food borne illness. The facility census was 77 with 71 residents receiving an oral diet.

Inspectors wroteBased on record review, staff interviews, and review of the facility policy titled, Medication Orders, the facility failed to ensure a stop date was implemented, not to exceed 14 days for psychotropic medications for four of nine residents (R) (R31, R56, R59, and R40) reviewed for unnecessary medications.

Inspectors wroteBased on observations, staff interviews, record review, and review of the facility policy titled, Resident Assessment - Coordination with PASARR Program, the facility failed to refer one of 35 sampled residents (R) (R33) for a preadmission screening and resident review (PASARR) level two. The deficient practice had the potential to place the resident at risk for medical complications, unmet needs, and a diminished quality of life.

Inspectors wroteBased on observations, staff interviews, and review of the facility policy titled, Medication Storage In The Facility, the facility failed to ensure one of three medication carts was locked and secured when left unattended by the nurse. This deficient practice created the potential for residents, unauthorized staff, and visitors to have access to medications and biologicals stored on the medication cart. The facility census was 77 residents.

Inspectors wroteBased on observations, staff interviews, and review of the facility policies titled, Enhanced Barrier Precautions and Bed Baths, the facility failed to utilize proper infection control techniques while providing care to one of 35 sampled residents (R) (R75) on Enhanced Barrier Precautions (EBP). The deficient practice had the potential for staff to spread infection to other residents in the facility.

Inspectors wroteBased on record review, observations, interviews, and review of the facility policy titled, Catheter Management - Indwelling Urinary Catheters, the facility failed to ensure an indwelling urinary catheter had a privacy cover for one resident (R)(R#22), of eight residents who had an indwelling urinary catheter.

Inspectors wroteBased on record review, interviews, and review of the facility policy titled, admission Criteria, the facility failed to make a referral for re-evaluation after a serious mental illness was newly diagnosed for one resident (R) (R#18), of fifteen residents reviewed for pre-admission screening and resident review (PASRR).

Inspectors wroteBased on record review, interviews, and review of the facility policy titled, admission Criteria, the facility failed to include serious mental illness diagnoses on the Level I Pre-admission Screening and Resident Review (PASRR) completed prior to admission for one resident (R) (R#13), of fifteen residents reviewed for PASRR.