Dfw Nursing & Rehab

Inspectors wroteBased on interview and record review the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility; the safety of individuals in the facility was endangered due to the clinical or behavioral status of the resident; the health of individuals in the facility would otherwise be endangered; and failed to develop and implement an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for one of five residents (Resident #1) reviewed for transfers and discharges. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident's right to be free from abuse for two (Resident #1 and #2) of 3 residents reviewed for abuse, in that: On 11/01/25 the facility failed to ensure that Resident #2 was not hit by Resident #1 causing Resident #2 to defend himself with his cane resulting in a laceration to Resident #1's left eyebrow. This failure could affect residents and result in abuse and injuries.

Inspectors wroteBased on interviews and record review the facility failed to ensure allegations of abuse were thoroughly investigated, prevent further potential abuse and mistreatment while the investigation was in process, and report the results of all investigations to the administrator or his or her designated representative and other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #4) of 3 reviewed for abuse. The facility failed to immediately investigate, protect the residents, and report allegations of abuse on 08/29/25 when Resident #4 reported a nurse hit her while in the shower, and the facility did not investigate or implement measures to protect the residents from further abuse. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized for 1 (Resident #3) for accuracy of records. The facility failed to accurately transcribe the admitting diagnoses for Resident #3. This failure can affect residents by putting them at risk for inaccurate and incomplete records.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the QA committee developed and implemented appropriate plans of action to correct identified quality deficiencies. The facility failed to provide the plan of correction (POC) for a deficiency of F610 cited at D and F842 cited at D on 11/20/2025. This failure could place residents at risk of abuse and not having abuse allegations investigated and inaccurate [NAME] records.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the residents had the right to be free from abuse for 1 of 5 residents (Resident #2) reviewed for abuse, neglect, and or exploitation. The facility failed to ensure Resident #2 was free from repeated resident-to-resident abuse by Resident #3, which occurred on 05/24/2025, 08/17/2025, and 10/03/2025. A past Immediate Jeopardy (IJ) was found on 08/17/25 and the immediacy was removed on 10/05/25. While the IJ was removed on 10/025/25, the facility remained out of compliance at a severity of actual harm due to the facility's need to monitor the effectiveness of their corrective systems. These failures could place residents at risk for continued abuse, decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide behavioral health services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for one (Resident #2) of five residents reviewed for behavioral health services. The facility failed to ensure Resident #2 received a psychology consultation or assessment after three incidents (5/24/2025, 08/17/2025, 10/03/2025) of resident-to-resident abuse where Resident #2 was the victim. This failure could place residents at risk for not receiving behavioral health services and a decline in quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to notify the ombudsman of the transfer or discharge before transferring or discharging the resident for 1 of 1 resident (Resident #1) reviewed for Discharge Rights. The facility failed to notify the ombudsman in writing of the transfer/ discharge of Resident #1 to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on observation, interview, and record review the facility to protect the resident's right to be free of sexual abuse by a resident for one of twelve residents (Resident #2) reviewed for abuse. The facility failed to protect Resident #2 from sexual abuse by another resident when Resident #1 led Resident #2 into his room on 09/07/2025 and sexually assaulted her. This failure placed residents at risk of subsequent abuse resulting in potential mental anguish, emotional distress, and physical harm.

Inspectors wroteBased on observation, interviews 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 and describes the services that are to be furnished in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for five (Residents #1, #8, #9, #11, and #12) of eight residents reviewed for care plans related to sexual activity with other residents. The facility failed to create care plans addressing known sexual relationships between residents for Residents #1, #8, #9, #11, and #12. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an allegation of abuse was reported immediately but not later than 2 hours after the allegation was made if the events that caused the allegation involved abuse to Health and Human Services for one (Resident #3) of twelve residents reviewed for abuse and neglect. The facility failed to report an allegation by Resident #3 (a discharged resident) that Resident #1 put drugs in a beer he gave her on 08/31/25 or 09/01/25. This failure could place residents at risk of being abused and lack of oversight by a state agency.

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 objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for4 (Res#1, Res#2, Res#3 and Res#4) of 5 residents reviewed for updated care plans. The facility failed to provide Resident#1,2,3,4 with updated care plans to reflected concerns for health and safety when leaving the facility unsupervised. An IJ was identified on 08/21/25. [...]

Inspectors wroteBased on interview, observations and record review, the facility failed to ensure 1 (Resident#1) out of 4 received adequate supervision when reviewed for accidents. The facility failed to provide Resident#1 with adequate supervision on 08/01/25 when Resident#1 left the unsupervised for 3 day's The facility was not made aware until 08/04/25 that Resident#1 had been admitted the hospital. An IJ was identified on 08/21/15. The IJ template was provided to the facility on [DATE] at 4:45 pm. While the IJ was removed on 08/22/25, the facility remained out of compliance at a scope of potential for more than minimal harm that is not Immediate Jeopardy and a severity level of isolated because all staff had not been trained on 08/22/25. Thia failure could affect all resident's health, safety and possible death.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility's only registered dietitian carried out the functions of food and nutrition services dietitian, according to the facility's Consultant Dietitian: Retainer Agreement. The facility failed to ensure that the registered dietitian worked a minimum of 16 hours a month and/or adjusted hours based on the facility's census. This failure could result in residents not maintaining or achieving optimal nutrition status.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure the stand-by refrigerator were dated and labeled. The facility failed to ensure the refrigerator food items were dated, labeled and securely stored. The facility failed to ensure the dry storage food items were dated and labeled. The facility failed to ensure that the steam tray table was cleaned daily. The facility failed to ensure that canned good food items were free of dents. The facility failed to ensure that dishwashing protocol was followed. The facility failed to ensure pureed food temperatures were logged. [...]

Inspectors wroteBased on 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 in this facility (one of one) reviewed for water management. The facility failed to implement a water management program/plan including: 1.) An assessment to identify where Legionella and other opportunistic waterborne pathogens could grow and spread; and2.) to implement measures to prevent the growth of opportunistic waterborne pathogens (control measures), and how to monitor them. This failure could place all residents at risk of water borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain safe and functional essential kitchen equipment in the facility's only kitchen. The facility failed to ensure the gas stove top oven had all turn knobs, did not leak grease, and was safe to touch when operating. The facility failed to assure the wall plug sockets were free of food and grease particles, and in safe operating condition. The facility failed to ensure the toaster oven was in safe operating condition. These failures could place residents at a risk for facility essential equipment not being maintained in working order.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a clean, safe, and functional environment for 6 of 10 rooms (Rooms 1, 2, 3, 4, 6, and 8) reviewed for environment. 1. The facility failed to repair the window in room [ROOM NUMBER].2. The facility failed to have baseboards, holes in the wall, and tile repaired in shared resident restrooms. 3. The facility failed to have soap and paper towels available in resident shared restrooms.4. The facility failed to repair the window, and repair holes in the wall and baseboards in room [ROOM NUMBER]. These failures could place residents at risk of living in an unsanitary, unsafe environment and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop, prepare, and periodically update menu items to meet residents needs and preferences. The facility failed to utilize and follow dietitian approved recipes for pureed food items. The facility failed to prepare an alternate menu in advance. The facility failed to ensure alternate menus were reviewed and approved to ensure it met the residents nutritional needs by the facility's dietitian. The facility failed to make reasonable efforts to develop a menu based on resident complaints about the lack of variety in food options. These failures could result in an adverse effect to resident's physical and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for two of the three hallways reviewed for pest control and the facility's only kitchen. The facility failed to ensure Resident #36 and Resident #28's room was free of flies on 7/29/25 and 7/30/25. The facility failed to ensure Resident #56 and Resident #28's room was free of flies on 7/30/25. This failure could lead to pest infestation and place residents at risk of insect transmitted diseases.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident's right to be free from abuse for one (Resident #65) of 5 residents reviewed for abuse, in that: On 7/27/25 the facility failed to ensure that Resident #65 was not slapped in the face by Resident #21 resulting in a bruise to the area of the right eye. This failure could result in resident abuse and injuries.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that an allegation of abuse was reported immediately to Health and Human Services for one (Resident #30) of three residents reviewed for abuse and neglect reporting. The facility failed to make a timely report of Resident #30's allegation that a staff member kicked a shoe at her, hurting her leg, on 07/19/25. This failure could place residents at risk of being abuse and lack of oversight by a state agency.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide evidence that all an allegation of abuse was thoroughly investigated for three residents (Resident #30, Resident #15, and Resident #81) of three residents reviewed for abuse and neglect reporting. 1. The facility administrator failed to provide evidence of a thorough investigation of an allegation of abuse by Resident #30 on 07/19/25, in which she alleged a staff member kicked a shoe at her and hurt her foot.2. The facility administrator failed to provide evidence of a thorough investigation of an allegation of abuse between Resident #15 and Resident #81 where there was a physical altercation between the both of them. This failure could place residents at risk of being abused and lack of oversight by a state agency.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident to meet a resident's medical, nursing, and mental and psychosocial needs in order attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one resident (Resident #30) of 24 residents reviewed for care plans. The facility failed to create a care plan addressing Resident #30's trauma history on 05/07/25, when her trauma screening assessment reflected her history of trauma. This failure could affect residents by placing them at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interviews and record review the facility failed to provide or obtain laboratory services only when ordered by the physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State Law, including scope of practice laws and promptly notify the ordering physician of the results for one (Resident #1) of two residents reviewed for labs. 1. Nursing staff did not ensure that labs (CBC, CMP, lipid, Valproic acid) were drawn every six months for Resident #1. 2. Nursing staff did not ensure that labs (Hgb and A1C) were drawn every three months for Resident #1. These failures could place residents at risk of a delay in receiving the necessary interventions to treat their medical condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. -The facility failed to ensure Resident #1 was free from deprivation of services and goods abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and prevent him from sexually abusing others, which could lead to harm to himself and others. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of eleven residents (Resident #1) reviewed for abuse, neglect, and exploitation. -The facility failed to implement policies and procedures to ensure Resident #1 was free from deprivation of goods and services abuse when the facility failed to have effective interventions and services in place to address the resident's inappropriate sexual behaviors and in-service staff on measures to properly handle the behaviors to prevent Resident #1 from sexually abusing others. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #2) reviewed for accidents. -The facility failed to ensure Resident #2 was provided with adequate supervision to prevent the resident from using nonprescription drugs at the facility. On 2/15/25 Resident #2 was found exhibiting signs of an overdose and was transported to the local hospital where he tested positive for marijuana. An Immediate Jeopardy (IJ) situation was identified on 5/19/25. While the IJ was removed on 5/20/25, the facility remained out of compliance at a scope of pattern with a potential for more than minimal harm that was not immediate jeopardy due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

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 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 two of six residents (Resident #1 and Resident #2) reviewed for care plans. 1. The facility failed to identify Resident #1 had physical and/or verbal behaviors on his admission MDS assessment dated [DATE] or develop a care plan to address the behavior. 2. The facility failed to develop a care plan to address Resident #2's substance abuse . This failure could place residents at risk of not receiving appropriate care and services.

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 no 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 including to the State Agency in accordance with State law through established procedures, for two of eleven residents (Resident #1 and Resident #2) reviewed for abuse, neglect and exploitation . 1. The facility failed to report to the state agency when Resident #1 exhibited sexually inappropriate behaviors to prevent further abuse or neglect towards Resident #1 and others. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure in response to allegations of abuse, neglect, exploitation or mistreatment have evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress for two of eleven residents (Resident #1 and Resident #2) reviewed for abuse, neglect and exploitation. 1. The facility failed to investigate an alleged violation when Resident #1 exhibited sexually inappropriate behaviors to prevent further abuse or neglect towards Resident #1 and others. 2. The facility failed to investigate when Resident #2 obtained and used nonprescription drugs at the facility, was found exhibiting signs of an overdose, and was transported to the local hospital where he tested positive for marijuana . [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the facility did not use verbal, mental, sexual, or physical abuse, corporal punishment, or involuntary seclusion for 2 of 3 residents (Resident #1 and #2) reviewed for abuse, neglect, and or exploitation. for 2 of 3 residents reviewed for abuse. (Resident #1 and Resident #2) 1. The facility failed ensure Resident #1 and #2's were free from resident-to-resident abuse, which occurred on 04/05/25. These failures could place residents at risk for decreased quality of life, decreased self-esteem and increase anxiety.

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 one of one kitchen reviewed for food and nutrition services. The facility failed to ensure food items were kept away from potential airborne contaminants (leaking sinks, dust particle and grease). This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in one of one kitchen reviewed for a clean environment. The facility failed to keep a safe and sanitary kitchen environment (leaking sinks, dirt towels and open hole outside the kitchen that was not covered to control kitchen contamination). This failure could place the residents at risk of exposure to infectious material.

Inspectors wroteBased on interviews and record review the facility failed to notify the resident's representative and ombudsman of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood for 1 of 2 resident (Resident #1) reviewed for Discharge Rights. The facility failed to notify Resident #1's resident representative in writing of the transfer/ discharge of the resident to a behavioral hospital, the reason for the transfer/discharge, and the right to appeal. This failure could affect the residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and appeal processes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be from abuse for 1 of 4 residents (Residents #1) reviewed for abuse. The facility failed to protect Residents #1 from a physical and verbal altercation on 01/22/25 with the Administrator. The Administrator pushed Resident#1, causing Resident#1 to fall. The incident was not reported or documented until after surveyor intervention on 01/23/25. The Administrator was not suspended until 01/23/25 at approximately 11:30 AM. An IJ was identified on 01/23/25. The IJ template was provided to the facility on [DATE] at 5:15 PM. While the IJ was removed on 01/25/25, the facility remained out of compliance at a scope of Isolated and a severity level potential for more than minimal harm that is not Immediate Jeopardy, due to the facility's need to implement corrective systems . [...]

Inspectors wroteBased on interview, observations and record review, the facility failed to ensure 1 (Resident#3) of 4 residents received adequate supervision and assistance devices to prevent accidents. The facility failed to provide Resident#3 with adequate supervision on 01/20/25 when he eloped from the facility. The non-compliance was identified as past non-compliance (PNC). The IJ began on 01/20/25 and ended on 01/20/25. The facility had corrected the non-compliance before the state's investigation began. These failures could affect all residents at risk of elopement.

Inspectors wroteBased on observation, record review and interview, the facility failed to immediately report failed to report abuse, neglect, exploitation, or critical incidents for 1 of 4 resident (Resident #1) reviewed for reporting. The facility failed to report an incident of resident to staff physical aggression/assault to HHSC. This failure could place residents at risk for abuse, neglect and incidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure complete and accurate incident/accident report for 1 (Resident#1) of 4 residents reviewed for incident reports. The facility failed to ensure Resident#1's incident report was completed on 01/22/25, which involved a verbal and physical altercation between Resident#1 and Administrator by LVN C. This failure could place residents at risk of inaccurate or incomplete information, resulting in the risk of abuse or neglect by staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for 2 of 7 residents (Resident #1 and Resident #5) reviewed for Accuracy of Assessments. 1. Resident #1's discharge MDS assessment dated [DATE] did not accurately reflect his current and MD order for Hemodialysis treatment in Section O. 2. Resident #5's quarterly MDS assessment dated [DATE] did not accurately reflect his current MD order for continuous oxygen treatment in Section O. These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

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 the facility's only kitchen . The facility failed to ensure items found in the reach-in refrigerator, were labeled with the name of container contents and the use by date, expired by date in the facility's only kitchen. The facility failed to ensure items found in the reach-in refrigerator was covered, tabled and dated. This failure could place residents at risk for food-borne illness and food contamination.

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 one of ten residents (Residents #19) reviewed for infection control. 1. The facility failed to ensure MA A performed hand hygiene and wore gloves when administering eye medication to Resident #19. 2. The facility failed to ensure MA A did not use his bare finger to remove Coreg 6.25 MG tablet out of Resident #19's. medication cup before administering her medications. These failures could place residents at risk of infectious diseases and cross contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 smoking areas reviewed for accidents and hazards. The facility failed to ensure smoking residents were free of fire hazards, when a propane grill was stored on the smoker's court. The facility failed to ensure the smoking area was free of fire hazards.

Inspectors wroteBased on record review and interview the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for one (Resident#19) of five residents reviewed for pharmaceutical services. The facility failed to specify blood pressure (BP) perimeters for Resident #19's order for Nifedipine 30 mg ER and Carvedilol 6.25 mg [both medications used to treat high blood pressure] when Resident #19's blood pressure reading was 105/72. MA A administered Nifedipine 30 mg and held Carvedilol 6.25 mg. These failures could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals used in the facility are labeled in accordance with professional standards, including expiration dates and with appropriate accessory and cautionary instructions for one (Resident #38) of five residents reviewed for storage of drugs and Biologicals. The facility failed to ensure MA B administered Amiodarone 200 mg (a medication used to regulate and lower heat rate) without checking vital signs or heart rate for Resident # 38 even with warning reflected on the medication bubble card to hold if heart rate was less than 60 BPM. These failure could place residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming, and personal hygiene for 1 (Resident #1) of 5 residents reviewed for ADLs in that: The facility failed for provide Resident #1 with timely incontinent care. This failure could put residents at risk of impaired skin integrity, and decreased feelings of self-worth and dignity.

Inspectors wroteBased on interviews and record reviews, the facility failed to immediately consult with the resident's physician and notify the resident representative when there was a significant change in the resident's condition or need to alter treatment significantly for one (Resident #1) of five residents reviewed for change of condition. -The facility failed to notify Resident #1's physician and responsible party when the resident had a fall on 3/27/24 and when the resident showed signs of increased lethargy and altered mental status as the week progressed. An Immediate Jeopardy (IJ) was identified on 04/22/24. An IJ Template was provided to the facility on [DATE] at 1:28 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services to residents with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents by not providing a call light system within reach for 1 of 25 (Resident #2) observed for call lights. The facility failed to ensure Resident #2 had a call light within reach so Resident #2 could communicate to staff he needed assistance. This failure affected residents by placing them at risk for not getting their needs met and diminishing their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan 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 one of 5 residents (Resident #2) reviewed for comprehensive resident centered care plans. The facility failed to ensure the comprehensive resident centered care plan for Resident #2 was implemented by not putting a fall mat in Resident #2's room. This failure could place residents, that are at risk for falls, to be injured by not putting interventions listed in resident's care plan.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide residents who were unable to carry out ADLs the necessary services to maintain good personal hygiene for 1 of 25 residents (Resident #1) reviewed for showers. The facility failed to ensure Resent #1 received showers/baths on scheduled shower/bath days. This failure affected residents by putting them at risk for a diminished quality of life, hygiene, and self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to must ensure that the resident's 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 25 (Resident #2) observed for call lights. The facility failed to ensure Resident #2 had a call light within reach so Resident #2 could communicate to staff he needed assistance. The facility failed to enure Resident #2 had a fall mat next to the bed as indicated in Resident #2's care plan. This failure affected residents by placing them at risk for not getting their needs met and diminishing their quality of life.

Inspectors wroteBased on interview, observations and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for three (Residents #1, #2, and #3) of six residents reviewed for incontinent care and catheter care, in that: Residents #1, #2, and #3 had an indwelling urinary catheter (a catheter which is inserted into the bladder, via the urethra and remains in to drain urine) without a physician's order, regarding a valid rationale for the placement of an indwelling urinary catheter. This deficient practice could place residents at-risk for infection due to improper care practice.

Inspectors wroteBased on observation and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, for daily living for four of six residents (Resident #1, #2, #3, and #4) review for environmental concerns. The facility failed to clean restrooms in Resident #1, #2, #3 and #4's room. This failure could affect residents by exposing them to an unsanitary and unsafe environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received adequate supervision and interventions for 3 of 6 residents (Resident #1, Resident #3, and Resident #5) reviewed for supervision and interventions. 1. The facility failed to use a Hoyer sling that was in good condition for Resident #1. 2. The facility failed to ensure Resident #3's wheelchair was in good condition. 3. The facility failed to safely supervise and transport Resident #5 to the facility at admission. These failures could place residents at risk for accidents and injury.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for 1 of 2 shower rooms reviewed for environmental concerns. The facility failed to ensure shower room [ROOM NUMBER] was functional. This failure could place residents at risk of not receiving showers and living in an unsafe and uncomfortable environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain and effective pest control program to ensure the facility was free of pests for 1 of 2 resident rooms (Resident #3's room) reviewed for pests. The facility failed to ensure an effective pest control program was implemented to prevent gnats in resident rooms. This could place residents at risk of foodborne illness and/or disease spread by pests.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible; and that each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #1) residents reviewed for supervision. The facility failed to adequately supervise Resident #1 and to ensure the back door by the kitchen was secured or monitored while getting groceries delivered. Resident #1, who had dementia and a history of wandering, eloped from the facility through the propped open door at unknown time on 10/10/23. The facility was unaware of Resident #1's elopement until another facility notified them Resident was at their facility. [...]

Inspectors wroteBased on observations, interviews, and record reviews 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 24 hours after the allegation is made for one (Resident #1) of 2 residents reviewed for reporting of allegations. The facility failed to report Resident #1's unwitnessed falls timely as required. This failure could place residents at risk of not having incidents reported as/when required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents in 24 of 51 (1, 2, 5, 9, 10, 11, 15, 16, 17,18, 19, 21, 23, 24, 25, 26, 27, 38, 39, 40, 42, 43, 45, and 49 and four of four (North, South, East and West) corridors reviewed for environment. The facility failed to maintain all displaced, cracked, broken, and missing wall, floor, and ceiling tiles. The facility failed to repair rusted, worn, scraped, peeling and gouged paint on doors and door frames of the room bathrooms and corridors. The facility failed to maintain the buckled flooring in the therapy room in a safe manner. This deficient practice could place residents at risk of a diminished quality of life due to an unsafe and unmaintained environment.

Inspectors wroteBased on observation, interview, the failed to provide a private meeting space for residents' monthly Resident Council Meeting for 7 of 10 confidential residents reviewed Resident Council. The facility failed to provide a private space area for the monthly Resident Council Meetings. This failure could place residents who attend the monthly Resident Council Meetings at risk of not being able to voice their concerns due to a lack of privacy.

Inspectors wroteBased on 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 (Resident #54) of five residents reviewed for pharmacy services. 1. The facility failed to ensure the MAR and TAR for Resident #54 was initialed immediately after administering their narcotic medication. This failure placed residents at risk of not having their MARs/TARs signed after receiving their medication which could lead to overdose of the medication.