Dayton Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made to Health and Human Services Commission (HHSC) for 4 of 4 residents (Residents #1, #2, #3 and Resident #4) reviewed for abuse and neglect. 1. The facility did not report allegation of abuse involving Resident #1 and Resident #2 until 19 hours after they were aware of the incident. 2. The facility did not report an allegation of abuse involving Resident #3 until almost 22 hours after they were aware of the incident. 3. The facility did not report an allegation of abuse involving Resident #4 until almost 9 hours after they were aware of the incident. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 15 Residents (Resident #15) who were reviewed for pain management. The facility failed to ensure the WCN assessed for pain and medicated Resident #15 with PRN pain medication prior to wound care and then failed to stop wound care when Resident #15 yelled out in pain multiple times. This failure could place residents who received wound care, who had chronic pain conditions, who received as needed pain medication, or who received routine pain medications at risk for not having their pain addressed causing undue suffering.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary psychotropic medications (is a medication used: without adequate indication for its use) for 2 of 8 residents (Residents #1 and #37) reviewed for unnecessary medications.* The facility did not have appropriate diagnoses for Resident #1's Risperdal (antipsychotic) and bupropion (antidepressant) and #37. * The facility did not have appropriate diagnoses for Resident #37's duloxetine (antidepressant). This failure could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate indication.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use) for 4 of 8 residents (Residents #1, # 3, #5, and #37) reviewed for unnecessary medications. * The facility did not have appropriate diagnoses for medication for Residents #1, #3, #5, and #37. This failure could place residents at risk for unintended, harmful events attributed to the use of a medication without the appropriate indication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was provided and received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen and 6 of 18 residents (#3 #5, #8, and 3 de-identified residents) reviewed for palatable food. The facility failed to provide meal services in a manner to ensure food served was appetizing to residents for 1 of 2 meals observed for palatability and for Residents #3 #5, #8, and 3 de-identified residents. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents received food prepared in a form designed to meet individual needs for 1 of 2 meals, reviewed for nutrition services. The facility failed to ensure the lunch meal served on 09/16/25 had the appropriate consistency for the meat and au gratin potatoes serving for the pureed textured diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and served under sanitary conditions for 1 of 1 kitchen, 1 of 2 refrigerator, 2 of 5 walls, and the dishwasher reviewed for food served under sanitary conditions. The facility failed to ensure sandwiches were dated and labeled in 1 of 2 refrigerators. The facility failed ensure the 2 of 5 walls were free of black streaks of an unknown substance. The facility failed to ensure the dishwasher was maintained with sanitizer level at 50ppm. These failures could place residents at risk for food contamination, food borne illness 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 3 of 15 residents reviewed for infection control. (Residents #3, #4, & #15) 1. The facility failed to ensure the WCN performed proper hand hygiene every time she changed gloves during wound care for Resident #3. 2. The facility failed to ensure the Wound Care Nurse performed proper hand hygiene and used a clean applicator for each separated area of the wound during wound care for Resident #4. 3. The facility failed to ensure the Wound Care Nurse performed proper hand hygiene every time she changed gloves during wound care for Resident #15. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to treat each resident with respect and dignity for 1 of 4 residents (Resident #3) reviewed for resident rights.* The ADON did not knock on Resident #3's room door prior to entering the room. This failure could place residents at risk for decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 2 residents reviewed for resident rights. (Resident #5) * The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #5. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state.

Inspectors wroteBased on observation, interview and record review, the facility failed to consult with the resident's physician and notify the representative when there was 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 15 residents (Resident #15) reviewed for quality of care. The facility failed to notify the WC physician or physician of Resident #15's increase of pain during wound care observed on 09/16/25. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessments accurately reflected the resident's status for 2 of 18 residents reviewed for accuracy of assessments. (Residents #13 & #15) 1. The facility failed to ensure Resident #13's most recent quarterly assessment captured the resident's daily Aspirin as an antiplatelet. 2. The facility failed to ensure Resident #15's most recent quarterly assessment captured the current number of unstageable pressure ulcer as 2 unstageable pressure ulcers. These failures could place the residents at risk of not receiving the appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 1 of 3 residents (Resident #15) reviewed for pressure injuries. The facility did not ensure WCN performed all the treatments for Resident #15 on 09/16/25 without surveyor intervention for 1 of 4 wounds. This failure could place residents at risk of improper wound management, deterioration in existing pressure injuries, infection, and pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals to meet the needs of each resident for 1 of 5 residents (Resident #12) for pharmacy services.* The facility did not clarify Resident #12's physician order for Flonase when the order was unclear. MA D administered Resident #12's Flonase nasal spray (used to treat allergies) 1 spray to each nostril during medication pass. The physician order indicated 1 spray nasal. This failure could place residents at risk of not receiving the therapeutic dosage of their medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service. The facility did not ensure the gas stove was in working order on 09/15/25. One of six gas stove burners (left back) did not light automatically, when the knob was turned to the on position on 09/15/25. This failure could place residents who eat out of the kitchen at risk for injury and under-cooked food and risk of food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 (A Hall) of 3 hallways reviewed for environment. An empty unlocked resident room was being used as a storage room on A Hall and contained potentially unsafe items. This failure could result in residents coming into contact with potentially unsafe items.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. * The facility did not ensure steam table lids did not have brown colored buildup on the inside edges.* The facility did not ensure baking sheets did not have brown colored buildup on the outside edges.* The facility did not ensure muffin pan did not have brown colored buildup on the inside and outside edges.* The facility did not ensure saucepans did not have brown colored buildup on the inside and outside of the pans. These failures could place all residents who eat from the kitchen at risk for foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to ensure an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and help prevent the development and transmission of communicable diseases and infections was established and maintained to prevent the spread of infections for all residents in the facility. The facility did not maintain a system of trending infections within the facility for the months of July 2023 through July 2024. This failure could place residents at risk of cross contamination and the development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 2 of 12 residents reviewed for accuracy of assessments. (Resident #'s 4 and 12) The facility did not accurately complete the MDS assessment to indicate Resident #4 was not receiving an anticoagulant and no longer received an antidepressant medication. The facility did not accurately complete the MDS assessment to indicate Resident #12 smoked. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident 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 2 of 18 residents reviewed for care plans. (Resident #s 2 and 3) The facility did not develop a care plan for Resident #2's trauma induced wound to her right heel. The facility did not develop a care plan for Resident #3's Hospice services. These failures could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident's drug regimen was free of unnecessary medication for 1 of 12 residents reviewed for unnecessary medication (Resident #5) The facility did not monitor Resident #5 for side effects of the anticoagulation medication Eliquis (a blood thinning medication). This failure could place the residents at risk for adverse consequences of the anticoagulant medication.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access, for 1 of 1 medication reviewed for security. The facility did not ensure venlafaxine ((Effexor) an antidepressant) was stored securely when it was left unattended at the nursing station. This failure could place residents at risk for harm by misappropriation of property and drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide basic life support, including CPR to a resident requiring such emergency care and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 31 residents reviewed for CPR. Resident #1 was found unresponsive on [DATE] around 4:00 a.m. by CNA B who immediately notified LVN A. LVN A failed to verify Resident #1's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 2.5 hours after the resident was found to be unresponsive. The facility did not immediately provide CPR and call 911 for Resident #1 who was a full code (wanted all possible life saving measures in the event his heart or breathing stopped) when the resident was found unresponsive by CNA B. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care, consistent with professional standards of practice to prevent pressure injury and does not develop pressure injury unless the individual's clinical condition demonstrated that they were unavoidable; and a resident with pressure injury receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure injuries from developing for 2 (Resident #1 and Resident #2) of 10 residents reviewed for pressure injuries in that: 1. [...]

Inspectors wroteBased on interview and record review , the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (Resident #1) of 10 residents reviewed for quality of care. The facility failed to coordinate care with the orthopedic surgeon and attending NP/MD of Resident #1's change in skin condition to RLE surgical area, addressing a scab, dark or discolored skin on top of resident's right foot identified in 02/14/2024. No documentation of an assessment or treatment performed to Resident #1's pressure injury/wound to top of right foot and/or no coordination or communication with orthopedic surgeon or attending physician/NP regarding pressure injury/wound identified on 02/14/2024 by orthopedic surgeon. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the physician was consulted for a change of condition for 1 of 10 residents reviewed for notification of changes. (Resident #2) Resident #2 returned to the facility from the hospital on [DATE]. Hospital discharge records included a blister to Resident #2 left heel. The facility did not consult or notify the physician of the blister to left heel for treatment orders after the resident returned from the hospital on [DATE]. This failure could place residents at risk for delay in treatment and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 10 residents reviewed for care plans. (Resident #4) The facility failed to develop a comprehensive person-centered care plan including an active problem of pressure injuries for Resident #4. Resident #4 was not care planned for new pressure injuries identified on 03/01/2024. These failures could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment or no more than 21 days after admission for 1 of 10 residents reviewed for comprehensive plans of care. (Resident #3) The facility did not develop a comprehensive care plan within 7 days of the completion of the comprehensive assessment or no more than 21 days after admitted on [DATE] and readmitted on [DATE] for Resident #3. Resident # 3 had no comprehensive care plan from 02/02/2024 to 03/20/204. Resident # 3's care plan should have been completed by no later than 2/17/2024. Resident #3 has cardiac issues and risk that must be monitored. This failure could place residents at risk of not receiving appropriate care and services.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that are accurately documented for 1 (Resident #5) of 10 residents reviewed for accurate medical records in that: 1. LVN H failed to complete the initial admission assessment documentation on Resident #5 when he was admitted to the facility on [DATE]. 2. LVN H failed to document on the MAR/TAR indicating what medication Resident #5 admitted with and whether any of the medications were administered during Resident #5's short stay in the facility on 03/4/2024 to 03/05/2024. This failure could place residents at risk for misinformation about professional care provided.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse of residents were reported immediately to the administrator for 1 of 10 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure all allegations of abuse or neglect were reported to the Administrator/Abuse Coordinator immediately. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 kitchen reviewed for food service. The facility did not have clean pots, pans, skillets, baking sheets, baking pans, and steam table pans clean of encrusted grease deposits. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stove in the kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition. Five of the 6 burners had residue and debris. This failure could place the residents at risk of a fire and not having safe operating equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate MDS was completed for 3 of 16 residents (Residents #11, 13, and #14) reviewed for MDS assessment accuracy. The facility did not accurately code Residents #11, #13, and #14's MDS for smoking when they were smokers. This failure could place residents who smoked at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medical record of each resident was accurately documented in accordance with accepted professional standards and practices for 3 of 3 residents (Residents #11, 13, and #14) reviewed for medical records. The facility failed to evaluate and document Residents #11, 13, and #14 as smokers and complete smoking assessments. This failure could place residents who smoke at risk of not having accurate documentation of smoking status and safety assessment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 10 window air conditioners (living room and dining room), 1 of 3 halls for unsecured chemicals (Hall A) and 16 of 35 windows screens (2 bent and 14 missing) and the grounds near the facility for unsecured chemicals reviewed for environment. 1. The facility failed to ensure gaps around the air conditioners were sealed to prevent pests, rodents and warm air from entering the facility. 2. The facility failed to ensure chemicals were in a secured location and flammable chemicals were stored in a secured location away from the facility. 3. The facility failed to ensure all window screens were intact for 16 of 35 windows. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide or obtain from an outside source dental services to meet the needs of 1 of 12 residents reviewed for dental services. (Resident #17) The facility did not assist Resident #17, who had no teeth, with a dental service consult. This failure could place the residents at risk for not receiving care and services to maintain their highest practicable mental, physical, and psychosocial well-being.