Denton Rehabilitation and Nursing Center

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs 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 2 (Resident #8 and Resident #42) of 19 residents reviewed for care plans. The facility failed to care plan Resident #8's nail trimming to be done by nurses due to her contracture of the hands and diagnosis of type 2 diabetes mellitus. The facility failed to care plan Resident #42's diagnosis of type 2 diabetes mellitus. This failure could affect residents by placing them at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene for 1 (Resident #8) of 3 residents reviewed for ADL care. The facility failed to trim and maintain the fingernails of Resident #8, who had contractures of the hands. This failure placed residents at the facility at risk of diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to consult with the physician regarding a change in condition for 1 (Resident #1) of 4 residents reviewed for change of condition. The facility did not consult with Resident #1's physician about his pattern of refusing to wear his CPAP (continuous positive airway pressure machine for the treatment of sleep apnea) on 2/22/26, 2/23/26, and 2/24/26; removing his oxygen by nasal canula at times; or his low oxygen saturation on 2/25/26. These failures could place residents at risk of having delayed treatments or worsening conditions.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain clinical records that were complete and/or accurate for 1 (Resident #1) of 4 residents reviewed for clinical records in that: -The facility did not document a nursing assessment or progress note for Resident #1 when he refused his CPAP on 02/22/26 and 02/24/26.-The facility did not document a nursing assessment or progress note for Resident #1 when his oxygen saturation was low on 02/25/26. These failures could place residents at risk for wrong or missed diagnoses and/or treatments.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for 1 (Resident #2) of five residents reviewed for accident hazard. The facility failed to ensure that a container of germicidal (substance that destroys germs and microorganism) wipes was not left inside Residents #2's room on 10/07/2025. This failure could prevent the residents from having an environment that was free from toxic chemicals.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one (Residents #1) of eight residents reviewed for medication storage. The facility failed to ensure that Resident #1's collagen powder (medication used for wound care) for wound care was not inside the room on 10/07/2025. This failure could place residents at risk of misuse of medications that could lead to overdosing or underdosing.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for seven (Resident #195, Resident #200, Resident #193, Resident#202, Resident#65, Resident#16, and Resident #204) of sixteen residents reviewed for Privacy and Confidentiality. 1. The facility failed to ensure LVN C closed the door while flushing Resident #195's IV and disconnecting his IV bag on 05/27/2025. 2. The facility failed to ensure LVN D did not leave Resident #200, Resident #193, Resident #202, Resident #65, Resident #16 and Resident #204, medical information on top of the medication care unattended on 05/27/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 7 of 15 resident rooms on the 100 hall (Resident rooms #1, #2, #3, #4, #5, #6, and #7), and all the hand rails on the 500 hall, reviewed for environment. 1. The facility failed to ensure Resident rooms #1, #2, #3, #4, #5, #6, and #7 were thoroughly cleaned and sanitized. 2. The facility failed to ensure the handrails on the 500 hall were thoroughly cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for three (Residents #196, #197, and #198) of sixteen residents reviewed for Accuracy of Assessments. 1. The facility failed to ensure Resident #196's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). 2. The facility failed to ensure Resident #197's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on oxygen therapy. 3. The facility failed to ensure Resident #198's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on oxygen therapy. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for six (Residents #29 #88, #193, #194, #197, and #198) of sixteen residents reviewed for Care Plans. 1. The facility failed to ensure Resident #29 was care planned for the resident's bed being placed in a low position and a fall placed alongside their beds for fall risk. 2. The facility failed to ensure Resident #88 was care planned for oxygen therapy on 05/09/2025. 3. The facility failed to ensure Resident #193 was care planned for CPAP on 05/17/2025. 4. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for six (Residents #88, #193, #196, #197, #198, and #244) of twelve residents reviewed for respiratory care. 1. The facility failed to ensure that Resident #88 had an order for continuous oxygen use. 2. The facility failed to ensure Resident #193's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs), breathing mask (used to receive medications by breathing in mist through nose and mouth), and CPAP (continuous positive airway pressure: [...]

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 the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 2. The facility failed to ensure prepared food in the dry storage, refrigerator and freezer was labeled and dated when stored. 3. The facility failed to ensure expired food in the refrigerator and freezer was discarded. 4. The facility failed to ensure all foods stored in the freezer and refrigerator was properly sealed. These failures could place residents at risk for cross contamination and air-borne illnesses.

Inspectors wroteBased 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 three (Resident #10, Resident #41 and Resident #195) of sixteen residents reviewed for Infection Control. 1. The facility failed to ensure CNA F performed hand hygiene and changed gloves while providing incontinent care to Resident #10 on 05/28/2025. 2. The facility failed to ensure CNA G performed hand hygiene and changed gloves while providing incontinent care to Resident #41 on 05/28/2025. 3. The facility failed to ensure LVN C wore a gown while flushing and disconnecting Resident #195's IV on 05/27/2025. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 2 of 12 residents (Resident #143 and Resident #194) reviewed for dignity. The facility failed to treat Resident #143 and Resident #194 with dignity and promote enhancement of their quality of life when the residents were not provided privacy bags for their catheter bags. This failure placed residents at risk of not having their right to a dignified existence maintained.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from physical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms for 1 of 6 residents (Resident #17) reviewed for physical restraints. The facility failed to ensure Residents #17 had physician orders for the bolster pads on the mattress. This failure could prevent the residents from moving freely in and out of their beds and not from being restrained.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 3 residents (Residents #1) reviewed for assisted nutrition and hydration. The facility failed to ensure Resident #1 was weighed monthly, according to her physician orders and her personalized care plan. This failure could prevent the facility from detecting if the resident was experiencing excessive weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored properly in locked compartments and under proper temperature for two (Cart #1 and Cart #2) of three nurses' carts observed for storage of drugs and biologicals. 1. The facility failed to ensure that LVN D locked Cart #1 before providing wound care to Resident #89 on 05/27/2025. 2. The facility failed to ensure RN A would not store Lorazepam (medication used to treat anxiety disorders) on Cart #2 on 05/28/2025. These failures could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications and not receiving the full benefit of the medication.

Inspectors wroteBased on observation, 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 set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for three of (Resident # 14, Resident #48, and Resident #75) of six residents reviewed for Care Plans. The facility failed to ensure Resident #14 and Resident #75 were care planned for oxygen administration. The facility failed to ensure Resident #48 was care planned for CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open). [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four (Resident #77, Resident #14, Resident #48, and Resident #75) of ten residents reviewed for respiratory care. The facility failed to ensure Resident #77 and 48's nebulizer masks were properly stored. The facility failed to ensure Resident #14 and Resident 75's nasal cannulas were properly stored. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #45 and Resident #29) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #45 and Resident #29's rooms was in a position that was accessible to the resident. This failure could place the residents at risk of being unable to obtain assistance when needed and not to get help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan was reviewed and revised by an interdisciplinary team for one (Resident #77) of six residents reviewed for revised Care Plan. The facility failed to ensure Resident #77's care plan was revised to reflect discontinued use of tube feeding. This failure could place the resident at risk of current needs not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in (1 of 1) kitchen reviewed for dietary services., in that: 1) Dietary staff failed to seal, label, and date refrigerator and freezer food items . 2) Dietary staff failed to remove items which have frost built up inside the container (bag). These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased 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 one (Resident #1) of five residents observed for infection control. The facility failed to ensure that CNA B changed her gloves and performed hand hygiene while providing incontinence care to Resident #1. This failure could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on interview and record review, the facility must ensure residents were free of any significant medication errors for one (Residents #1) of five residents reviewed for medications. LVN A failed to correctly transcribe the physician order of methotrexate sodium (medication for rheumatoid arthritis) for Resident #1 on 11/02/23, resulting in the resident receiving more medication than ordered. This failure could place residents at risk for not receiving therapeutic effects of their medications to include a diminished health status.