Crestway Nursing & Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 (Cook A) of 11 dietary staff reviewed for qualified dietary staff, in that: The facility failed to ensure [NAME] A had a current had Food Handler Certificate. This failure could place residents who ate food from the facility's kitchen at risk of not having their nutritional needs met and place them at risk for food born illnesses.

Inspectors wroteBased on record reviews and interviews, the facility failed to notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of five residents reviewed for notification of changes. The facility failed to notify Resident #1's family when she expired (died) on [DATE]. This failure could result in the resident's family/RP not being aware of the resident's condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 6 residents out of 18 residents (Resident #3, Resident #4, Resident #8, Resident #7, Resident #11, and Resident #55) whose records were reviewed for assessments. 1. The nursing facility did not identify siderails were used as a restraint for Resident #32. The nursing facility did not identify siderails were used as a restraint for Resident #43. The nursing facility did not identify siderails were used as a restraint for Resident #74. The nursing facility did not identify siderails were used as a restraint for Resident #85. Resident #11's quarterly MDS, dated [DATE], inaccurately revealed the resident was receiving hospice care. 6. Resident #55's quarterly MDS, dated [DATE], inaccurately revealed the resident did not have surgical wound. [...]

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 that included measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs for 3 of 6 Residents (Resident #3, Resident #4 and Resident #7) whose Care Plans were reviewed. The facility failed to recognize Resident #3 used 1/4 side rails as a restraint and failed to implement interventions to ensure his safety. The facility failed to include Resident #4 used 1/4 side rails while in bed, that they were used as a restraint and failed to develop/implement interventions to ensure his safety. The facility failed to develop and implement interventions related to the fact Resident #7 had contractures on both wrists/hands and she used side rails while in bed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 3 of 9 Residents (Residents #1, Resident #2 and Resident #7) whose records were reviewed for oxygen use. Nursing staff failed to ensure Resident #1's oxygen concentrator was equipped with 2 filters while in use. Nursing staff failed to ensure Resident #2's oxygen concentrator was equipped with 2 filters while in use. Nursing staff failed to ensure Resident #7's oxygen concentrator was equipped with 2 filters while in use. This deficient practice could affect any respiratory on oxygen therapy and could contribute to respiratory distress, infections, pneumonia and an overall decline in their physical condition.

Inspectors wroteBased on observation, interview and record review the facility failed to attempt to use appropriate alternatives prior to installing a side or bed rail, assess the resident for risk of entrapment, to review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation of the bed rails for ? of 6 Residents (Resident #3, Resident #4, Resident #7 and Resident #8) whose records were reviewed for restraints. The facility failed to identify the use of bilateral use of side rails as a restraint and failed to ensure Resident #3's safety since his admission date of 05/02/2025. The facility failed to identify the use of bilateral use of side rails as a restraint and failed to ensure Resident #4's safety since his admission date of 8/10/22. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 3 of 5 (Resident #3, #61, and #82) residents reviewed for unnecessary medications., in that: 1. The facility failed to monitor the behaviors and side effects of Resident #3's Remeron for depression and Buspirone for anxiety. 2. The facility failed to ensure there was a correct diagnosis for the use of Zyprexa for agitation for Resident #61. 3. Resident #82 received psychoactive medications for which he did not have a documented diagnosis. This failure could lead to residents being prescribed medications without indication and place residents at risk of unnecessary side effects and a decline in overall health.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards of food service safety for 1 of 1 kitchen, in that: The dry storage area had 2 boxes of funnel cake mix with an expiration date of 10/31/2024 hand written on the box. The dry storage area had a box of 9 juice cups with spillage and gnats in the box. The dry storage area had 2 containers of sugar with the lids not secured. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 (Resident #3, Resident #70) of 18 residents reviewed for infection control practices. 1. CNA-C changed her gloves without sanitizing or washing her hands during emptying Resident #3's colostomy bag on 07/17/2025. 2. RT-J changed her gloves without washing her hands or using hand sanitizer while providing tracheostomy care for Resident #70. 3. LVN-I touched curtains, bed rails with gloves before she administered medication through peg tube for Resident #3. These deficient practices could place residents at risk for cross contamination and infections. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to be informed and make treatment decisions for 2 of 23 residents (Resident# 2 and Resident #82) reviewed, in that: Resident's #2 and #82 did not sign their own consent forms to receive psychoactive medications. This deficient practice could result in residents receiving medications and treatments for which they have not given informed consent.

Inspectors wroteBased on interview and record review the facility failed to refer all residents to PASARR with newly evident or possible serious mental disorder for level II resident review for 1 of 6 Residents (Resident #4) whose records were reviewed for PASARR assessments. The facility failed to refer Resident #4 for PASARR (Preadmission Screening and Resident Review) Level II comprehensive evaluation when Resident #4 was diagnosed with Major Depressive Disorder (causes a persistently low or depressed mood and a loss of interest in activities that you used to enjoy) on 4/1/23 and undifferentiated Schizophrenia (serious mental health condition that affects how people think, feel and behave. It may result in a mix of hallucinations, delusions, and disorganized thinking and behavior) on 2/16/24. [...]

Inspectors wroteBased on interviews and record review, the facility failed to review and revise resident care plans after each assessment for 1 of 18 residents (Resident #55) reviewed for care plan revision/timing. The facility failed to ensure Resident #55's care plan addressed changes in his smoking status regarding the resident could keep his cigarettes and lighter because he was very safe smoker after smoking assessment, dated 05/08/2025. This deficient practice could affect residents' care and services and may cause a delay in treatment and/or decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received proper treatment and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 of 1 Resident (Resident #9) whose records were reviewed for assessments. LVN/Treatment Nurse K failed to assess Resident #34's feet during a head-to-toe assessment and did not identify he had significantly long toenails and two ingrown toenails. This deficient practice could affect any resident and could contribute to pain, infections and loss of toes.

Inspectors wroteBased on observations, interviews, 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 2 residents (Resident #62) reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #62 on 07/17/2025, CNA-A did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #17) of 2 residents reviewed for enteral nutrition. When LVN-B flushed Resident #17's gastrostomy tube with 30 ml of water, LVN-B pushed water inside the barrel of the syringe with a plunger, instead of using gravity. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia.

Inspectors wroteBased on observations, interview, and record reviews, the facility failed to provide pharmaceutical services to administer drugs and biologicals that meet the needs of each resident for 1 of 9 (Cart #1 on 400 hall) medication carts observed for expired medication in that: The facility failed to remove expired medications from medication cart #1 1 bottle of Gentle Lax and 1 bottle of Extra Strength Tylenol 500mg This failure could result in residents decreased health response or misuse of medication.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #7) out of 18 residents reviewed for medical records. Resident #7's psychiatric doctor added the resident's general anxiety as one of the resident's diagnosis and prescribed diazepam 2 mg three times a day for anxiety, but the facility did not add the new diagnosis to the resident's medical record. This failure placed residents at risk for missed treatment and medications which could result in decline in heal and well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 (Resident #16) of 18 residents reviewed for environmental concerns. Resident #16's oxygen cylinder was stored in the resident room, but per the facility policy indicated Do not oxygen cylinder in any resident room or living area. This failure could place residents at risk of a diminished quality of life and respiratory status due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 6 residents (Resident #4) reviewed for residents' rights. The facility failed to ensure LVN A locked the medication cart computer screen and left an unidentified resident's (Resident #4) information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons.

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 the 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 for 1 of 6 residents (Resident #1) reviewed for care plans: The facility failed to ensure Residents #1's comprehensive care plan reflected he received a mechanically altered diet. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 6 residents (Resident #2) reviewed for care plan revisions. The facility failed to ensure Resident #2's care plan was comprehensive and updated to reflect Resident #2 had an indwelling catheter and a stage 4 pressure ulcer to the sacrum. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

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 1 of 1 resident (Resident #3) reviewed for enteral feeding: LVN C failed to flush Resident #3's enteral feeding tube per physician's orders. This deficient practice could place residents who received enteral nutrition and medications at increased risk of aspiration, infection, bloating discomfort, and not receiving the full benefit of the medications administered.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 2 of 2 medication carts reviewed for storage of drugs and biologicals. The facility failed to ensure the medication cart on 200 hall and 300 halls were locked and secured. These deficient practices could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide special eating equipment for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 of 1 resident (Resident #1) reviewed for special eating equipment and assistance when consuming meals. The facility failed to ensure Resident #1 was provided with an Adult Sip Cup to meet Resident #1's need for assistance while eating. This failure could place residents at risk for harm from weight loss, diminished independence, and self-esteem.

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 each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #2) reviewed for accidents and supervision. 1. Resident #1 was transferred without a mechanical lift on 10/25/24 and experienced pain to her right leg/sustained a distal fracture 2. Resident #2 was transferred by a single staff member instead of the required two during a mechanical lift on 09/25/2024 and the mechanical lift tipped over, dropping the resident, and resulting in a bump and laceration to her nose. The noncompliance was identified as PNC. The IJ began on 9/24/2024 and ended on 11/27/2024. The facility had corrected the noncompliance before the investigation began. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 5 residents (Resident #4) reviewed for grievances. The facility failed to fully investigate and follow up with Resident #4's and Resident #4's family member about a grievance report on 1/12/25 of being sprayed with an unknown substance by an unknown staff member. This failure could place residents at risk for not having their grievances resolved.

Inspectors wroteBased on interview and record review the facility failed to ensure resident's care plans were revised by the interdisciplinary team after each assessment for 1 of 5 Residents (Resident #1) whose records were reviewed for care plan timing and revision, in that:. Resident #1's Care Plan did not reflect she required a mechanical lift for transfers. These deficient practices could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care 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 disease and infection for 1 of 4 residents (Resident #2) reviewed for infection control: The facility failed to ensure CNA N and CNA O wore the proper PPE while transferring Resident #3 who was on EBP. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 12 staff (Respiratory Therapy Director) reviewed for staff qualifications. The facility failed to ensure the Respiratory Therapy Director, while working as a Respiratory Therapist, was licensed to practice as a respiratory therapist in the state of Texas from August 2021 to August 2024. This failure could place residents at risk of not receiving care and services from staff who were properly licensed.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one (Resident #2) of four residents reviewed for abuse. The facility failed to keep Resident #2 free from abuse when CNA A roughly provided bed mobility assistance and incontinent care on 02/11/2025 and 02/13/2025. The noncompliance was identified as past non-compliance IJ. The noncompliance began on 02/15/2025 and ended on 02/19/2025. The facility corrected the non-compliance before the investigation began. This deficient practice could affect any resident and result in emotional and physical abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 residents (Resident #1) reviewed for pharmacy services. 1. The facility failed to administer Resident #1's ordered seizure medications of Lamictal and Phenobarbital on 2/18/2025 and 2/19/2025, resulting in 5 missed doses of Lamictal and 2 missed doses of Phenobarbital. 2. The facility failed to administer Resident #1's medication (Ativan) per physician's orders for two doses on 2/19/2025 and 2/20/2025. This PRN medication was ordered to be administered as needed for seizure and was administered for agitated and anxious behaviors. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #4) of 5 residents reviewed for care plans. The facility failed to implement and ensure Resident #4 was assessed for physical and occupational therapy as care planned, dated 10/25/24. This deficient practice could place residents at risk of not being provided with the necessary care or services and implementing personalized plans developed to address their specific needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide specialized rehabilitative services such as but not limited to physical therapy, speech therapy-language pathology, occupational therapy, respiratory therapy, and rehabilitative services for mental illness and intellectual disability or services of a lesser intensity as required in the resident's comprehensive plan of care for 1 (Resident #4) of 5 residents reviewed for specialized rehabilitative services. The facility failed to ensure Resident #4 received PT/OT/ST evaluations and treatments per physician order dated 11/15/2024. This deficient practice could place residents who required rehabilitative services at risk of a decline or decrease in their physical capabilities.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents were free of significant medication errors for 1 (Resident #1) of 3 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 was free of significant medication errors when Resident #1 was administered another resident's medications, atorvastatin (medication to treat high cholesterol), labetalol (medication to treat high blood pressure), and hydralazine (medication to lower blood pressure) by LPN A on 11/09/2024. This failure could place residents at risk of adverse reaction related to taking medications not ordered by the physician.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #1) of 4 residents reviewed for infection control. 1. The facility failed to ensure LVN A and CNA B wore a gown while providing wound care and peri care to Resident #1 who was on EBP (enhanced barrier precautions) on 1/25/2025. 2. The facility failed to ensure LVN A who was the weekend wound care nurse used appropriate infection control principles including wound care cleansing technique, hand hygiene/glove changes during care on 1/25/2025. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the right to personal privacy during personal care for 4 of 5 residents (Resident #5, Resident #6, Resident #7, and Resident #8) reviewed for dignity. 1. The facility failed to ensure Resident #5 was provided with privacy when checking for incontinence. 2. The facility failed to ensure Resident #6 was provided with privacy during incontinent care. 3. The facility failed to ensure Resident #7 was provided with privacy when checking for incontinence. 4. The facility failed to ensure Resident #8 was provided with privacy during incontinent care. These failures could affect residents by contributing to poor self-esteem, and decreased self-worth and quality of life.

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 2 of 6 medication carts (Respiratory Treatment Cart #1 and Wound Treatment Cart #2) reviewed for medication storage. 1. The facility failed to ensure the respiratory treatment cart on the 300 hall was locked. 2. The facility failed to ensure the wound treatment cart was locked on (2) occasions. This failure could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased on observations, interviews, 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 7 of 7 residents (Residents #1, Resident #2, Resident #4, Resident #5, and Resident #6, Resident #7, and Resident #8) reviewed for infection control. 1. The facility failed to use proper infection control practices during perineal care for Resident #1. 2. The facility failed to use proper infection control practices when checking Resident #2 for incontinence. 3. The facility failed to use proper infection control practices during incontinent care for Resident #4. 4. The facility failed to use proper infection control practices when checking Resident #5 for incontinence. 5. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #8) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed Resident #8's following care areas: Cognitive Loss/Dementia, Visual Function, Communication, Urinary Incontinence and Indwelling catheter, Psychosocial Well-Being, Activities, Nutritional Status, Feeding Tube, Dehydration/Fluid Maintenance, Pressure Ulcer, Physical Restraints, and Functional Abilities related to self-care and mobility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals, and preferences for 2 of 2 (Resident #8 and Resident #9) reviewed for respiratory care. 1. The facility failed to ensure the aerosol tubing for Resident #8 was replaced after it was found on the floor. 2. The facility failed to ensure the aerosol tubing for Resident #9 was replaced after it was found on the floor. This deficient practice could affect residents and place them at risk for respiratory infection and decline in health.

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, that are complete; and accurately documented for 1 of 6 residents (Resident #1) reviewed for administration: The facility failed to ensure Resident #1's Nurse Note, dated 9/29/24 and authored by LVN A, documented the insertion of a suprapubic catheter (a surgically created tube that drains urine from the bladder through a small incision in the lower abdomen) and urine output. Also, LVN A stated she did not check and document catheter care on 9/29/24. This failure could result in residents receiving catheter care not receiving continuity of care and a diminished quality of life.

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 11 residents (Resident #2) reviewed for infection control, in that: The facility failed to ensure Resident #2's catheter bag was anchored on the bed rail and not lying on the floor. This failure could result in the spread of disease and expose residents with catheters to infections and a diminished quality life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that items stored in the reach in refrigerator were labeled after opened. This failure affect the residents who received meals from the kitchen and place them at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were accurately documented for 5 of 30 residents (Residents #14, #20, #27, #32, and #236) , reviewed for administration. The facility failed to ensure blood pressures for Residents #14, #20, #27, #32, and #236 were documented as the same on different shifts on the same days when administering blood pressure medications. This failure could result in decreased continuity of care, medication errors, illness, and inaccurate assessments.

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 the resident rights 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 of 6 residents (Resident #27), reviewed for care plans. Resident #27 had an order to remove his mitten restraints every 2 hours for ten minutes but the care plan documented to visually observe the mitten restraints every 2 hours. This failure could place residents at risk of not receiving necessary services to meet their needs, pain, blood flow complications, and contractions.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 5 of 79 residents (Resident #5, #7, #10, #11, and #12) reviewed for elopement. 1. Resident #5 was admitted on [DATE] with diagnoses which included dementia and was assessed on 02/26/2024 as a wander risk at 9 out of a possible 11 for high risk. Resident #5 walked out of the facility on 03/16/2024 around 3:00 to 4:00 PM and was discovered 13 miles away on a public street and returned to the facility at 9:40 PM. 2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for documentation. Resident #'1's electronic medical record did not contain complete and accurate documentation that the resident received three meals on 3/9/24 and 3/10/24. This failure could result in residents' records not accurately documenting delivery of meals, any assistance provided to the resident in consuming meals,; and could result in documentation not showing meal consumption, loss of weight and dehydration, and a diminished quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 8 of 20 residents (Residents #11, #8, #14, #16, #5, #12, #2, and #10) reviewed for respiratory care in that: The facility did not ensure Residents #11, #8, #14, #16, #5, #12, #2, and #10 had an order to deflate their tracheostomy tube [a tube that is inserted through a hole in the neck and into the windpipe to assist with breathing] cuffs. This deficient practice could affect residents and result in infection, not receiving therapeutic benefits of oxygen, diminished quality of life, and respiratory compromise.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify, consistent with his or her authority, a resident's representative when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 20 residents (Resident #4) reviewed for notification of changes in that: The facility failed to notify Resident #4's responsible party when Resident #4 had unexpectedly removed her tracheostomy tube [a tube inserted through the neck and the windpipe to assist with breathing] and was immediately transferred to a local hospital. This deficient practice could place residents at risk not having their responsible party notified of changes.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 20 residents (Resident #1) reviewed for comprehensive care plans in that: Resident #1's care plan did not address Resident #1 preferred for his tracheostomy tube's [a tube inserted through the neck and the windpipe to assist with breathing] cuff to be deflated. This deficient practice could affect residents and place them at risk for insert applicable risk/ in residents not receiving appropriate treatment and services or activities:

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 20 residents (Resident #19) reviewed for storage of drugs. Resident #19's Novolog [a type of injectable, short-acting medication that helps control high blood sugar levels] insulin pen was left unsecured and unattended on top of the 100 Hall nurse medication cart. This deficient practice could place residents at risk of medication misuse and diversion.

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 3 of 20 residents (Resident #1, Resident #20, and Resident #5) reviewed for infection control in that: 1. Prior to performing Resident #1's tracheostomy [a hole in the neck and into the windpipe to assist with breathing.] care, RT A did not maintain sterile technique when putting on sterile gloves. 2. While performing Resident #20's tracheostomy care RT B placed a contaminated split 4x4 gauze on Resident #20's tracheostomy. 3. While performing Resident #5's incontinent care, CNA D did not perform hand hygiene between glove changes. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents and hazards. Resident #1 sustained a fall on 12/17/2023 during an attempted transfer when CNA B opted not to follow facility policies and procedures and care plan which require a 2 person physical assist. Resulting is Resident #1 having intense pain requiring PRN medications This failure could place residents requiring assistance with ADLs in danger of injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that all allegations 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 other officials which included to the State Survey Agency, in accordance with State law through established procedures for one (Resident #1) of 5 residents reviewed for abuse/neglect. The facility staff did not report a fall Resident #1 sustained a fall on 12/17/2023 during an attempted transfer when CNA B opted not to follow facility policies and procedures which require a 2 person physical assist. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 11 residents (Resident #1 and Resident #2) reviewed for accidents and supervision, in that: 1. Resident #1 was not transferred properly to prevent a fall with injury of left femur fracture. 2. Resident #2 was not provided personal care in a manner to prevent a fall without injury. These failures could place residents who were at risk for falls at risk for avoidable accidents and could result in a decline in physical condition. The non-compliance was identified as past non-compliance. The non-compliance began on 08/09/2023 and ended on 10/24/2023. The facility had corrected the non-compliance before the survey began.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 2 resident (Resident #1, and Resident #2) reviewed for care plans. 1. The facility failed to develop a person-centered care plan for Resident #1 that would addresss resident's activities of daily living including transfers until after a fall on 08/09/2023. 2. The facility failed to ensure Resident #2's care plan was implemented for bed mobility resulting in a fall on 09/18/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 (Resident #182 and Resident #13) of 22 residents reviewed for advanced directives, in that: 1. Resident #182's OOH-DNR form was improperly executed via verbal consent and not signed by the resident's representative. 2. Resident #13's OOH-DNR was improperly executed by a physician rather than the resident's representative. This deficient practice could place residents at-risk of having their end of life wishes dishonored and of having CPR performed against their will.

Inspectors wroteBased on observation, interview, and record review the facility failed to notify, consistent with his or her authority, the resident representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 4 residents (Resident #10) reviewed for notifications. The facility failed to notify Resident #10's guardian that he was sent to the hospital. This failure could place residents at risk for their rights not being honored and could result in mental anguish, frustration, and anxiety for the resident and the family.

Inspectors wroteBased on interview and record review, the facility failed to review and revise a person-centered care plan for 1 of 22 Residents (#66) in that: 1. The facility failed to revise a comprehensive care plan that addressed Residents #66's Do not resuscitate (DNR) order status. This deficient practice could place residents at risk of not having a change in code status followed by the facility.

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 1 of 1 kitchen, in that: The facility failed to ensure that the four (4) of the food container items in the storeroom were labeled with by use dates. This failure could place residents who received meals and snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interview, and record review, the facility failed to provide resident abuse prevention training to 4 of 25 staff reviewed including ( C.N.A. LVN, RN staff, and the Activity Director). The facility failed to ensure that 4 of 29 staff reviewed had completed their mandatory abuse annual training. This deficient practice could place residents at risk for care by C.N.A., LVN, and Activity staff who have been insufficiently trained while working in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 10 of 25 staff (CNAs D, E, F, H, I, J, RNs B and C, and LVNs A and B) reviewed for training, in that: The facility failed to ensure that 10 of 25 staff (CNAs D, E, F, H, I, J, RNs B and C, and LVNs A and B) staff had completed their mandatory QAPI annual training. This failure could place residents at risk for care by CNA, RN, and LVN staff who have been insufficiently trained while working in the facility.

Inspectors wroteBased on interview, and record review, the facility failed to provide effective behavioral health mandatory training for four (4) of twenty-five (25) staff reviewed including C.N.A, LVN staff and the Activity Director. The facility failed to ensure that 4 of 25 staff had completed their mandatory behavioral health annual training This deficient practice could place residents at risk for care by C.N.A.,LVN, and Activity staff who have been insufficiently trained while working in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the daily nurse staffing information for three(3) of 3 resident hallways. The Director of Nursing did not direct that the daily nursing staffing information including the total number of staff and the actual hours worked by staff was posted on 3/15/23. This failure could place residents at risk by the facility not revealing the staffing ratios that are scheduled to meet resident care needs.