Diboll Nursing and Rehab

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain personal hygiene for 4 of 8 residents (Residents #9, #1, #4, and #21) reviewed for ADL care. 1. The facility failed to clean/groom Resident #9's fingernails that had a dark brown substance underneath them on 8/25/25 and 8/26/25.2. The facility failed to trim, clean/groom Resident #21's fingernails that were about 1/2 inch in length and had a dark, brown substance underneath them on 8/25/2025.3. The facility failed to trim, clean/groom Resident #4's fingernails that were about 1/2 inch in length on 8/25/2025 and 8/26/2025.4. The facility failed to trim, clean/groom Resident #1's fingernails that were about 1/2 inch in length and had a brown substance underneath them on 8/25/2025 and 8/26/2025. [...]

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 food safety requirements and kitchen sanitation. The facility failed to ensure all foods stored in the refrigerators were not kept past their expiration dates and were labeled and dated. The facility failed to ensure all foods stored in the dry storage area were not kept past their expiration dates. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observations, interviews, and record reviews 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 5 residents (Resident's #1, #21, and #22) and 3 of 5 staff (CNA A, ADON and CNA E) reviewed for infection control. 1. The facility failed to ensure CNA A changed gloves and washed or sanitized her hands when providing care to Resident #21 on 8/25/2025.2. The facility failed to ensure ADON wore a gown during wound care to Resident #1 who was on enhanced barrier precautions on 8/26/2025.3. The facility failed to ensure CNA E wore a gown during incontinent care to Resident #22 who was on enhanced barrier precautions, and she failed to wash or sanitize her hands on 8/27/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza and the pneumococcal immunizations of 4 of 5 residents (Residents #1, #4, #7, and #21) reviewed for immunizations. The facility failed to document education was offered for the influenza and pneumococcal vaccinations to Residents #1, #4, #7 and #21. These failures could place residents at risk for contracting a viral disease that could spread through the facility and cause respiratory complications, and potential adverse health outcomes.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents could call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside for 4 of 6 residents (Residents # 6, #22, #26, and #27) reviewed for resident call system.1. The facility failed to ensure Residents #6, #22, and #26 had a call light within reach on 8/25/25 and 8/26/2025.2. The facility failed to ensure Resident #27 had a call light that was functional. Resident #27 did not have a pull cord attached to the call box on 8/25/25. This failure could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment 1 of 3 halls (room [ROOM NUMBER]) reviewed for environment. The facility failed to repair the window in Resident #8's room [ROOM NUMBER] that had a broken frame that was frayed and splintered on 8/26/2025 and 8/27/2025. This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 1 of 5 residents reviewed for respiratory care (Residents #21). The facility failed to ensure the external filters of Resident #21's oxygen concentrators was free of dust build up from 8/25/2025-8/27/2025. These failures could place residents who require respiratory care at risk for respiratory infections, breathing in dust and allergens, decreased effectiveness of oxygen concentrators, and exacerbation of respiratory distress.

Inspectors wroteBased on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 5 months (February 2025) reviewed for pharmacy services. The facility failed to have 2 witness signatures on attached page of controlled substances at time of disposal on 2/11/25. This failure could put residents at risk for misappropriation and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 resident personal refrigerators reviewed for food safety (Resident #3 and Resident #14). The facility failed to ensure the refrigerator for Resident #3 did not contain expired cheddar cheese bars or canned sausage. The facility failed to ensure the refrigerator for Resident #14 did not contain expired pineapple tidbits, fruit cups or pineapple juice. This failure could place resident at risk for food borne illnesses.

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 reviewed for dietary services. 1. The Dietary Aide failed to properly wear hair net while in the kitchen on 7/15/2024. 2. Dietary Staff failed to check and log the dishwasher temperature and sanitation for month of July 2024. 3. Dietary Staff failed to properly label and dispose of leftovers from the refrigerator. 4. Facility staff failed to clean Resident #7's water pitcher. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 1 resident group (resident council) reviewed for quality of life. The facility failed to ensure that staff were not talking on their cell phones while providing care to residents. The facility failed to ensure that staff did not speak rudely to residents. This failure could place residents at risk of decreased feelings of self-worth.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 4 hallways (north hallway and south hallway) reviewed for environment, in that. 1. The nursing supply storage room on the south hallway was open and accessible to visitor or resident tampering/contamination of sterile products and supplies kept in the nursing supply storage room. 2. The shower room on the north hallway (100 hallway) was open and accessible to residents and staff staff allowing access to toxic cleaners. These failures could place residents at risk for unsafe environment resulting in injury or unsafe conditions due access to toxic cleaners and visitor or resident tampering/contamination of sterile products and supplies kept in the shower room and nursing supply room.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 3 of 3 residents (Resident #9, Resident #22 and Resident #139) reviewed for beneficiary notice. The facility failed to ensure Resident #9, Resident #22 and Resident #139 was given a Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN) when discharged from skilled services at the facility prior to covered days being exhausted. [...]

Inspectors wroteBased on 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 7 residents (Resident #6) reviewed for care plans. The facility failed to develop a comprehensive care plan that included Resident #6's nutritional status and requirement of a feeding tube. This failure could place residents at risk of not having individual needs met and cause residents not to receive needed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 7 residents (Resident #3) reviewed for accidents hazards and supervision, in that: CNA E and CNA F failed to properly transfer Resident #3 on 7/15/24. This deficient practice could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were properly stored and inaccessible to unauthorized staff and residents for one resident (Resident #16) of six residents reviewed for medication storage. The facility failed to ensure topical medications and skin cleanser were stored in a manner to prevent possible diversion or contamination. This failure could place residents at risk for drug diversion and access to medications that could cause harm, sickness, or hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews 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 2 of 12 residents (Resident #6 and Resident #27) reviewed for infection control. The facility failed to ensure the COTA (certified occupational therapy assistant) followed enhanced barrier precautions when she provided care to Resident #6 on 07/15/2024. The facility failed to ensure LVN (licensed vocational nurse) followed infection control precautions when she administered medications to Resident #27 on 07/26/2024. These failures could place residents at risk for cross contamination and infection.

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 essential equipment. The facility did not ensure the gas stove was in working order. One of six gas stove burners (back right) had excessive carbon buildup and the burner did not fully light on 7/16/2024. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food.

Inspectors wroteBased on observation, interviews and record review, the facility failed to immediately consult with the physician of a significant change in the resident's physical, mental, psychosocial status; or a need to alter treatment significantly for 1 (Resident #35) of 8 residents reviewed for parameters to notify Physician of critical lab levels The facility failed to notify Resident # 35's primary care physician of critical low blood sugar readings of (46 mg/dl on 05/17/23 and 44mg/dl, on 05/21/23). The facility failed to train the staff of when to report changes to the physician. An Immediate Jeopardy (IJ) situation was identified on 06/13/23 at 3:00 PM. The IJ template was provided to the facility on [DATE] at 3:03pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 of 8 residents (Resident #35), reviewed for quality of care. The facility failed to obtain orders for finger stick blood sugars for resident #35 and to follow their policy on Management of Hypoglycemia, (low blood sugar), when resident # 35's blood sugar reading was at critical levels of 46mg/dl on 05/17/23 and 44mg/dl on 05/23/23 and hold parameter for Insulin if blood sugar reading is at a critical level of below 70mg/dl. Resident #35 experienced sweating and shakiness when her blood sugar fell below 80mg/dl. Resident #35 had no orders for finger stick blood sugars and no parameters for holding Insulin for blood sugar levels below 70mg/dl. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 5 of 5 months reviewed. (January 2023-May 2023) The facility did not have RN coverage for 4 days in January 2023. The facility did not have RN coverage for 17 days in February 2023. The facility did not have RN coverage for 17 days in March 2023. The facility did not have RN coverage for 3 days in April 2023. The facility did not have RN coverage for 2 days in May 2023. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the designated individual responsible for the infection control program was certified in infection prevention . This failure has the potential to affect all 36 residents of the facility due to potential outbreaks infections. (There was no full time Infection Preventionist at the facility.)

Inspectors wroteBased on interview and record review, the facility failed to review and revise the person-centered care plans to reflect the current condition for 3 of 5 residents of the facility (Residents #7, #17, and #18). The facility failed to ensure Residents #7, #17, and #18 care plans conferences and reviews were held quarterly. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow established policy regarding smoking, smoking areas, and smoking safety for 2 (back porch smoking area and gazebo smoking area) of 2 smoking areas. The facility failed to keep cigarette butts out of the plastic trash can containing paper and plastic in the smoking area (back porch smoking area), and there were no red metal trash cans (fire-proof) available for residents to extinguish their cigarettes. The residents were putting their cigarettes out on the bricks of the building at the exit door next to the laundry (Gazebo smoking area). The residents were then placing the cigarettes in a coffee can and plastic bleach container at the doorway. This failure could place residents who smoke at risk of physical harm, burns, fires and lead to an unsafe smoking environment.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for all new and existing staff consistent with their expected roles, that included but are not limited to the mandatory training topics of communication, resident rights, abuse, infection control, dementia, and behavioral health for 9 of 13 employees (ADON, LVN G, Activity Director, FSS, Rehab Director, TNA C, CNA D, CNA E, CNA F) reviewed for training. The facility failed to ensure required trainings were provided to: ADON, LVN G, Activity Director, FSS, Rehab Director, TNA C, CNA D, CNA E, and CNA F. These failures could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to self-administer medications if the IDT determined that the practice was clinically appropriate for 1 of 1 resident (Resident #238) reviewed for medication self-administration. The facility failed to assess, obtain physician orders and IDT approval for Resident #238 to self-administer his own bolus G-tube feedings. This failure could place residents at risk of infection and aspiration.

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 15 residents reviewed for MDS assessment accuracy. (Resident #17) The facility incorrectly coded Resident #17 as having not received oxygen in previous 14 days while a resident on her MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being. Findings Include: Record review of the facility face sheet dated 6/13/2023 for Resident #17 indicated that she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses including: [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 3 of 6 residents (Residents #21, #34, and #238) reviewed for baseline care plans. The facility failed to develop a baseline care plan or comprehensive care plan within 48 hours of admission for Residents #21, #34, and #238. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 2 of 15 residents (Residents #7 and #34) reviewed for care plans. The facility failed to ensure Resident #7's care plan accurately reflected her hospice status. The facility failed to ensure Resident #34's care plan accurately reflected her ADL status. This failure could place residents at risk of not receiving appropriate care and interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 of 1 courtyard reviewed for accident hazards. The facility failed to store laundry detergent and bleach away from residents. These failures could place the residents at risk of accidents hazrds in the environment in which they live.

Inspectors wroteBased on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 12 months (February 2023, and May 2023) reviewed for pharmacy services. The facility did not have a licensed pharmacist and two witnesses initial the attached pages of the controlled medication destruction inventory sheets. This failure could put residents at risk for misappropriation and drug diversion.

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 6 residents (Resident #34) reviewed for infection control. TNA B failed to wash or sanitize her hands when changing gloves while performing incontinent care to Resident #34. TNA B failed to change her gloves when going from dirty to clean while performing incontinent care to Resident #34. This failure could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2023 for the second quarter January 1, 2023 to March 31, 2022) The facility failed to submit accurate licensed nursing coverage 24 hours a day for 1/3/2023, 1/27/2023, 3/2/2023 and 3/7/2023. These failures could place residents at risk for personal needs not being identified and met.