Countryview Nursing & Rehabilitation

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 (Resident #7) of 6 Residents reviewed for abuse. The facility failed to protect Resident #7 from verbal abuse when Resident #16 made mocking statements and gestures regarding Resident #7's personal hygiene, the Administrator, LVN B, DON and Social Worker were aware of the verbal abuse. The verbal abuse led to Resident #7 being fearful, avoiding Resident #16 and Resident #7's withdrawal from former social patterns in refusing to go to the dining room and activities. An IJ was identified on 08/14/25. The IJ template was provided to the facility on [DATE] at 10:13AM. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance or complaint in an anonymous manner for The facility failed to notify residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner for 1 of 1 facilities reviewed. This failure could place residents at risk of not filing a grievance without the fear of discrimination, reprisal, retribution, and their right to anonymously file their grievance.

Inspectors wroteBased on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for 3 of 3 areas (1 shower room, and 1 wooden cabinet inside of the shower room and exterior/interior front door), reviewed for accidents and hazards. 1. The facility failed to ensure that the exterior door to the Shower Room in the facility's Secured Unit was locked and secured.2. The facility failed to ensure that the Master lock on the wooden cabinet inside the Shower Room in the facility's Secured Unit was locked and secured.3. The facility failed to ensure that Resident #7 was supervised and did not have access to the Nurses Station and access the red button to open the front door. These failures could place residents at risk of accidents, injury, elopement, and consuming hazardous products. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one medication cart (600 hall) of the facility's two medication carts reviewed for medication storage. The facility failed to ensure that opened insulin pens,1) Lantus 100 unit/ml and 2) Insulin pro 100units/ml were properly labeled and dated before storing in the 600-hall medication cart. This failure could place resident at risk by diminishing the effectiveness, and therapeutic benefits of the medications and/or result in medication error by giving the wrong resident the wrong insulin.

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 for 1 of 1 kitchen reviewed. The facility failed to ensure that 1 of 1 dented can was removed from the rack in the dry pantry areaThe facility failed to ensure that Dietary X properly used hair restraints during food preparation. This failure could place residents at risk for food exposed to adulteration or potential contaminants. Findings Included:Observation and interview on 08/12/25 at 9:15 AM, the Dietary Manager stated she had been employed at the facility for four years. The initial tour of the kitchen revealed that in the dry storage area 1 of 1 dented can on the rack with the other canned items, instead of in the area labeled as Dented Cans Only, do not use. [...]

Inspectors wroteThe 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 one (Resident #2) of four residents reviewed for medication administration. The facility failed to ensure LVN A administered each medication separately via Resident #2's g-tube per physician's orderThis failure could place residents at risk for potential significant medication interactions such as medication-medication or medication-food interactions.

Inspectors wroteBased on observations, interviews, 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 (Resident #2) of 6 residents reviewed for infection control. 1. LVN L failed to don (to put on) PPE prior to performing the high contact resident care activity on a resident who was on enhanced barrier precaution. This failure could place residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. The facility failed to ensure Resident #1 was free from physical abuse. CNA A grabbed Resident #1's arm and twisted it and then CNA A put her hands on Resident #1's neck and choked her. The incident occurred on 03/03/25. An IJ was identified on 4/22/25. The IJ began on 03/03/25 and removed on 03/03/25. The facility took action to remove the IJ before the survey began. While the IJ was removed on 03/03/25, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm because all staff had not been trained on behavior management procedures, abuse, and trauma informed care plans. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature. The facility failed to provide food that was palatable and appetizing temperature for 1 of 3 meals observed on 7/29/24 (lunch) meal. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient staff to effectively conduct food and nutrition services for the facility's main dining room. The facility failed to serve meals, at the specific times posted, in the main dining room. This failure placed residents at risk of increased hunger, thirst, frustration, and decreased feelings of self-worth.

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 dietary services, in that: 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary staff failed to effectively reseal, label and date frozen food items. 4) Dietary staff failed to store dented cans on a separate shelf. 5) Dietary staff failed to remove scoop from sugar container. 6) Dietary staff failed to clean the deep fryer. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who require dialysis services receive such services consistent with professional standards of practice for 2 of 2 residents reviewed for dialysis services. (Residents #23 and Resident #24) The facility failed to keep ongoing communication with the dialysis facility for Resident #23 and Resident #24. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

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 5 of 18 residents( Resident #192, Resident #30, Resident #34, Resident #12, and Resident #23) and 7 of 8 staff (LVN A, LVN C, CNA C, CNA L, LVN K, CNA B, and CNA O) reviewed for infection control practices and transmission-based precautions. 1. LVN A failed to ensure Resident #192 had the proper cap in place to prevent infection in PICC line. 2. LVN A failed to wash his hands while passing medications to Resident #30 and Resident #34. 3. The facility failed to ensure the EBP (enhanced barrier precautions) were in place for Resident #192 on 07/28/24. 4. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents and/or the residents' representatives the right to participate in the development and implementation of his or her person-centered plan of care for 1 of 18 residents (Residents #19) reviewed for care plans. The facility failed to invite and include the input of the resident (Resident #19) and/or resident's representatives as members of the interdisciplinary team in the Care Plan Conference meetings on 4/19/24 and 7/19/24. These failures could place residents at risk of not having needs met by depriving them the opportunity to participate in the decision making regarding their care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed protect and promote the rights of the residents for 1 of 11 residents (Resident #27) reviewed for resident rights. The facility failed ensure LVN N provided privacy when she provided wound care to Resident #27 on 07/28/2024. This deficient practice could place residents at risk for loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident's property of 1 of 1 resident reviewed for abuse, neglect, and exploitation. (Resident #17) The facility did not implement their policy to report to HHSC when Resident #17 sustained a severe coffee burn on 8/16/23. This failure could place the residents at risk for further potential abuse, neglect, and injuries of unknown origin.

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, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to the State Survey Agency for 1 of 8 residents (Resident #17) reviewed for abuse and neglect. The facility failed to report to the State Survey Agency on 8/16/2023 immediately but no later than 2 hours after becoming aware Resident #17 sustained a severe coffee burn to his right thigh. This failure could place residents at risk of further potential abuse or neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program of activities based on the comprehensive assessment to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 7 of 12 residents (Resident #24, Resident #27, and 5 confidential residents) reviewed for activities. The facility failed to ensure quarterly activity assessments were completed for Resident #24, Resident #27, and 5 confidential residents to provide activities to meet their interests. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 18 (Resident #1) residents reviewed for accidents hazards and supervision. The facility failed to ensure Resident #1 did not keep cigarettes in her purse. The CNA D failed to ensure Resident #1 smoked only in the designated areas of the facility. These failures could place residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents reviewed (Resident #12) for incontinent care, or catheter care. CNA L failed to perform hand hygiene during Resident #12's continent care. CNA L failed to perform catheter care when Resident #12 received incontinent care. This failure placed residents who required assistance with incontinent care at risk for urinary tract infections, skin breakdown, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 1 of 1 resident (Resident #24) reviewed for fluid restriction. The facility failed to ensure Resident #24's 1 liter fluid restriction was monitored. This failure could place residents at risk for dehydration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided such care consistent with professional standards of practice for 1 of 4 residents (Resident #8) reviewed for respiratory care and services. The facility failed to properly store Resident #8's nebulizer (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs) mask while not in use. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure that licensed nurses were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 resident's needs (Resident #192). Three Licensed Vocational Nurses (LVN A, LVN C, and LVN H) provided Intravenous (IV) therapy to Resident #192 during the month July 2024, without certification of training for Intravenous therapy. This deficient practice could place residents requiring Intravenous therapy at risk from adverse effect from improper Intravenous (IV) therapy techniques.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1 of 1 resident reviewed for pharmacy services. (Resident #17) The facility failed to ensure Resident #17's methocarbamol (treatment of muscle spasms/pain) 500 milligrams one tablet 3 times daily was available for administration for 2 of the 3 doses due on 7/29/2024. This failure could place residents at risk for unrelieved or increased pain from muscle spasms.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 3 meal (the lunch meal) reviewed for nutritional adequacy, as evidenced by: The facility failed to follow the menu for the noon time (lunch) meal served on 7/28/24. This failure could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided drinks, including water and other liquids consistent with resident needs and preferences for one of thirteen residents reviewed for hydration. (Resident #17). The facility failed to ensure Resident #17 was served cranberry juice with all meals and not tea. This failure could lead to dehydration and urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received and consumed foods with the appropriate nutritive content as prescribed by the physician for 2 of 2 resident (Resident #'s 31 and 16) reviewed for large protein portions for 2 of 2 meals observed. The facility failed to ensure Resident #31 received a large meat portion, per physician's orders, on his lunch tray on 7/28/2024. The facility failed to ensure Resident #16 received a large meat portion, per physician's orders, on his breakfast tray on 7/30/2024. This failure could place residents who require large servings of meat at risk of not receiving their daily protein requirements and weight loss.

Inspectors wroteBased on interview and record review the facility failed to arrange an appointment with an outside resource for 1 of 6 residents (Resident #27) reviewed for the use of outside resources. The facility failed to ensure Resident #27's appointments with a dermatologist (specialty for skin disease, function) was scheduled after the order dated 11/25/2023 was received by the facility. This failure could place residents at risk of not receiving needed medical care.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 2 residents (Residents #8 and #12) reviewed for hospice services. The facility failed to obtain Resident #8 and #12's most recent hospice plan of care. The facility failed to ensure Resident #8 and #12's hospice plans of care accurately reflected their medication regimen. This deficient practice could place Residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent elopement for 1 of 5 residents (Resident #1) reviewed for accident hazards and supervision. 1. The facility failed to ensure Resident # 1 had adequate interventions to prevent elopement on 04/08/24 after he had verbalized and or attempted to leave the facility on 03/15/24, 03/17/24, 03/18/24, and 03/31/24. 2. The facility failed to prevent Resident #1 from eloping from the facility on 04/08/24. Resident #1 wheeled himself approximately 0.3 miles from the facility. An Immediate Jeopardy (IJ) situation was identified on 07/09/24 at 5:51 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. The facility failed to ensure their Medication Administration Policy was followed where a resident's medication will be administered in an accurate, safe, timely and sanitary manner. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 3 Residents reviewed for pharmaceutical services. (Resident #1) The facility failed to follow physician order to give Resident #1 Invega Sustenna prefilled syringe 234 MG/1.5ML injection once a month. Resident #1 missed Invega in October and began hearing voices telling him to harm himself and Resident #1 had to be admitted to a psychiatric facility. The facility failed to ensure their Medication Administration Policy was followed where a resident's medication will be administered in an accurate, safe, timely and sanitary manner. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 1 of 3 resident reviewed for accidents. (Resident #2) The facility failed to provide adequate supervision during breakfast meal which resulted in CNA C spilling hot coffee on Resident #2 abdomen and Resident #2 sustained blisters from the coffee. This failure could result in residents who drank coffee at risk of having burn accidents, pain, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were secured on 3 of 4 medication carts reviewed for pharmacy services. (500 Hall, 600 Hall and 800/900 Halls Medication Carts) - LVN B failed to ensure the Medication carts for 500 Hall and 600 Hall was not left unlocked, unsecured, and unattended. -DON failed to ensure the Medication cart for 800/900 Halls was not left unlocked, unsecured, and unattended. These failures could affect the residents, who received medications from those carts, by placing them at risk of drug diversions or misuse of medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, for 1 of 2 facility self-reported incidents reviewed for reporting to the State Survey Agency. (Incident #461859) The facility failed to report to Health and Human Services Commission within 2 hours when CNA C spilled hot coffee on Resident #2 abdomen, resulting in burn/blisters. This failure could place the residents at risk for increased risk for abuse and neglect.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 1 of 7 (Resident #1) residents reviewed for abuse. The facility staff did not implement their abuse policy when they did not report to the state agency or investigate Resident #1's scalp hematoma (a bad bruise that occurs when an injury causes blood to collect and pool under the skin; the pooling blood gives the skin a spongy, rubbery, lumpy feel) that was discovered on 09/21/23. This failure could place residents at risk for abuse and neglect due to staff not reporting or investigating incidents to rule out abuse and neglect.

Inspectors wroteBased on 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 forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 1 of 7 (Resident #1) residents reviewed for abuse and neglect. The facility staff did not report Resident #1's Resident #1's scalp hematoma (a bad bruise that occurs when an injury causes blood to collect and pool under the skin; the pooling blood gives the skin a spongy, rubbery, lumpy feel) that was discovered on 09/21/23 to the state agency. [...]

Inspectors wroteBased on interview and record review, the facility failed have evidence that all alleged violations are thoroughly investigated for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility did not provide evidence of a thorough investigation for Resident #1's scalp hematoma (a bad bruise that occurs when an injury causes blood to collect and pool under the skin; the pooling blood gives the skin a spongy, rubbery, lumpy feel.) which was first discovered on 9/21/23. This failure could place residents at risk of abuse and neglect due to the facility not performing a thorough investigation to rule out abuse and neglect.

Inspectors wroteBased on 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 3 of 5 (Resident #9, Resident #12, and Resident #25) residents reviewed for PASRR. The facility failed to ensure Resident #9 had quarterly PASRR IDT meetings. The facility failed to ensure Resident #12 had quarterly PASRR IDT meetings. The facility failed to convene Resident #25's initial PASRR IDT meeting. These failures could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services.

Inspectors wroteBased on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 13 residents (Resident #25, Resident #28, and Resident #30) reviewed for care plans. The facility failed to care plan that Resident #25 and Resident #28 were PASRR positive. The facility failed to ensure Resident #30's care plan reflected he had a condom catheter. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 3 of 13 residents reviewed for ADLs (Resident #16, Resident #17, and Resident #23). The facility failed to provide assistance with facial hair removal for Resident #16. The facility failed to ensure Resident #17, and Resident #23 received showers or bed baths as scheduled. These failures could place residents at risk of not receiving services and care, and a decreased quality of life.

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 4 of 4 staff (CNA B, CNA C, LVN D, and the Housekeeping Supervisor) reviewed for infection control. The facility failed to ensure the Housekeeping Supervisor covered the clean linen cart while passing out resident's personal laundry. The facility failed to ensure CNA B and CNA C changed gloves and performed hand hygiene while providing incontinent care to Resident #28. The facility failed to ensure LVN D changed gloves while providing wound care to Resident #20. These failures could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to assure residents who have authorized the facility in writing to manage any personal funds have ready and reasonable access to those funds for 2 of 2 residents (Resident #12 and Resident #23) reviewed for personal funds. The facility failed to ensure Resident #12, and Resident #23 had access to their personal funds when they requested it. This failure could place residents whose funds are managed by the facility at risk of not receiving their personal funds deposited with the facility and not having their rights and preferences honored.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 1 resident (Resident #20) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #20 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. Resident #20 did not incur any out-of-pocket cost. This failure could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have physician orders for the resident's immediate care for 1 of 13 residents (Resident #30) reviewed for admission physician orders. The facility failed to ensure Resident #30 had a physician order for a condom catheter. This failure could place resident at risk for not receiving appropriate care, treatment services, and at risk for infection.

Inspectors wroteBased on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 13 residents (Resident #9) reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #9's medications on the MDS assessment on 04/15/2023 when the MDS reflected Resident #9 was on the antidepressant and Resident #9 had no order for an antidepressant. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 2 residents (Resident #25) reviewed for baseline care plans. The facility failed to ensure Resident #25 had a baseline care plan completed within 48 hours of admission. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on interview and record review the facility failed to develop, review, and revise a comprehensive care plan of each resident that included measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 13 residents (Resident #9) reviewed for care plans. The facility failed to ensure Resident #9's care plan was updated and revised to reflect she was not taking any antidepressant medications. These failures could cause the resident to not receive the correct care impacting the patient's health and/or serious illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #28) reviewed for incontinence. The facility failed to ensure Resident #28 was provided prompt incontinent care. This failure could place residents at risk for urinary tract infections, skin breakdown, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 10.34%, based on 3 errors out of 29 opportunities, which involved 1 of 6 residents (Resident #10) reviewed for medication administration. The facility failed to ensure Resident #10 received Methocarbamol (treat muscle spasms/pain, and Tylenol (treat aches and pain). This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

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 under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (Hall 6/8/9) reviewed for storage of medications. The facility failed to ensure Hall 6/8/9 medication cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion.