Coryell Health Rehabliving at the Meadows

Inspectors wroteBased on interview and record review, the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 5 of 8 medication carts (Medication Aide Cart and Nurse Cart for Unit 2, Medication Aide Cart and Nurse Cart for Unit 3, and Medication Aide Cart for Unit 4) reviewed for pharmacy services. The facility failed to record narcotic receipt and reconciliation documentation for the medication aide cart on unit 2, the nurse cart on unit 2, the medication aide cart on unit 3, the nurse cart on unit 3, and the medication aide cart on unit 4 during each shift change. This failure could place residents at risk of drug diversions and could result in missed medication, diminished health and well-being. [...]

Inspectors wroteBased on 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 kitchen sanitation. The facility failed to ensure the kitchen dishwasher contained sanitizer. The facility failed to ensure expired items were removed from the reach in refrigerator in the dining room containing residents' beverages. (individual milk cartons with best by date of 02/08/26). The facility failed to ensure food remained off the ground in the walk-in freezer. (individual serve cups of ice cream). The facility failed to ensure CK A, CK B, and CK H properly sanitized a food thermometer before and after use when taking food temperatures for lunch service on 02/10/26. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and communicable disease and infections for 4 (Resident #35, Resident #52, Resident #84, and Resident #88) of 8 residents and 1 of 1 laundry room reviewed for infection control practices, in that: The facility failed to ensure CNA C performed hand hygiene while seated with Residents #88 and #52 during lunch and while assisting Residents #35 and #84 during the lunch meal on 02/10/2026. The facility failed to monitor and ensure laundry room practices were followed to prevent the spread of infection. in laundry room was observed unclean with thick lint clusters behind and around the dryers; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments for 1 (medication cart #1) of 2 medication carts reviewed for pharmacy services. The facility failed to ensure that MC #1 was locked when staff were not present. This failure could place residents at risk of overdose, hospitalization, and pain.

Inspectors wroteBased on interviews and records review the facility failed to ensure that a resident receives treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, for one (Resident #1) of two residents reviewed for foot wounds. The facility's Agency CNA put tennis shoes on Resident #1 after being told not to put tennis shoes on Resident #1 who had a blister on the back of her left heel which later became a pressure ulcer. This failure could place residents at risk of discomfort and worsening of foot blister or wound. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #1) of three residents reviewed for pain. The facility failed to assess Resident #1 pain level on [DATE] when family reported Resident #1 was hurting and needed pain medication. These failures could place residents at risk of increased pain, hospitalization, and a decreased quality of life.

Inspectors wroteBased on interviews and records 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 #1)of three residents review for medication administration. The facility failed to administer Resident 1's antibiotic on [DATE] as was ordered on [DATE]. This failure could place residents at risk of ineffective therapeutic effect.

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 one of one kitchen reviewed for sanitation. 1. The facility failed to ensure sanitation practices of cleaning the ice machine, cleaning the microwave, hand hygiene, hair restrained, and clothing sleeves not touching food items were occurring in the kitchen. 2. The facility failed to ensure temperature logs were being completed. 3. The facility failed to ensure labeling and dating of all food items in the kitchen. 4. The facility failed to ensure all items were covered and stored properly. These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for eight (Resident #3, Resident #11, Resident #15, Resident #16, Resident #30, Resident #31, Resident #38, and Resident #66) of twenty residents reviewed for rights, in that: The facility failed to ensure Resident # 3, Resident #11, Resident #15, Resident #16, Resident # 30, Resident # 31, Resident # 38, and Resident #66 were assisted with feeding in a dignified manner. These failures put residents at risk of experiencing humiliation, degradation, and a decreased quality of life.

Inspectors wroteBased on Interview and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs by having an indication for use of 5 (Residents #39, 72, 146, 69, and 70) of 5 residents reviewed. The facility failed to have adequate indications for routine medications for Residents #39,72,146,69, and 70. This failure could potentially affect all residents that receive routine medications from receiving unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of six residents reviewed for developing and implementing abuse and neglect policies, in that: Facility staff failed to report to the Administrator, who was the Abuse Prevention Coordinator, potential incidents of abuse that occurred on 4/23/2024 when: 1. RN B was allegedly heard making a derogatory statement about Resident #1 to CNA A. 2. RN B was allegedly heard making a derogatory statement about Resident #1 to CSM C. 3. RN-B was allegedly heard making a derogatory statement about Resident #1 in front of CSM D This failure placed residents at risk of abuse, neglect, or exploitation.

Inspectors wroteBased on interview, observation and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 4 of 6 residents (Resident #35, #16, #43, #210) reviewed for ventilator orders. The facility failed to label and date O2 tubing and water concentrator bottles weekly, per physician's orders, for Resident #35, #16, #43, #210. This failure could result in residents receiving incorrect or inadequate ventilator support and could result in a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 2( Hall E treatment cart , Wound care) of 9 medication/treatment carts reviewed for medication storage in that: Treatment Cart #1 was left unattended and unlocked at the nurse's station on 9/25/23 and 9/26/23. Wound care cart #2 was left unlocked outside of a resident room This failure could allow residents, unsupervised access to prescription and over the counter medications. Findings Include: Observation on 9/25/2023 at 10:21am revealed, Hall E treatment cart was unsupervised and unlocked at the nurse's station. RN A was sitting out of eyesight of the cart at the nurse's station, . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to respect the residents' rights to personal privacy of medical record on 1 (Resident # 213) of 1resident reviewed for privacy in that: CMA A failed to lock the screen on a computer used for documenting residents' medications. This failure could place residents at risk of personal information being exposed to unauthorized persons, loss of dignity and low esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure each residents drug regimen was free from unnecessary drugs by having an indication for use for 3 (Residents #40,19 and 38) of 3 residents reviewed for unecessary drugs. The facility failed to have adequate indications for routine medications for Residents #40, 19 and 38. This failure could potentially affect all residents that receive routine medications from receiving unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive food that accommodates their preferences for 1 out of 1 resident (Resident #206) reviewed for food and nutrition services. The facility failed to complete required documentation to ensure Resident #206 was served a regular texture diet based on her preference and assessment. This failure could place residents at risks for a diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to implement their written policies and procedures for reporting all allegations involving abuse, neglect, and injuries of unknown source in accordance with the state law for 1 of 1 resident (Resident #1) reviewed for abuse and neglect The facility failed to provide evidence that an allegation of abuse was reported to law enforcement officials immediately. The facility reported the allegation of abuse on 08/20/23. This failure could place the census of 99 residents at risk for abuse and neglect.