Eagle Pass Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure assessments accurately reflected thestatus of the residents for 3 of 6 residents (Resident #1, #2 and #3) reviewed for MDS assessments. 1. The facility failed to ensure Resident #1s cardiac pacemaker was reflected as an active diagnosis on the quarterly MDS assessment dated [DATE]. 2. The facility failed to ensure Resident #2's use of an opioid medication was reflected in the quarterly MDS assessment dated [DATE]. 3. The facility failed to ensure Resident #3's anxiety was reflected as an active diagnosis on the quarterly MDS assessment dated [DATE]. These deficient practices could place residents at risk of inadequate care.

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 observed for kitchen sanitation. 1. The facility failed to ensure a tray of prepared and poured glasses of thicken beverages were dated. 2. The facility failed to ensure opened jar of jalapenos dated 05/05/2025 were refrigerated. 3. The facility failed to ensure a large opened plastic container of vanilla cream icing with lid open to air and partially used was sealed properly. 4. The facility failed to ensure half used bottle of salad dressing was refrigerated. 5. The facility failed to ensure a beverage container in the dining room with water was dated with prepared date. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a minimum of 80 square feet per resident in 46 of 46 resident rooms (A1 through A11, B12 through B23, C24 through C33, D34 through D40, E41 through E46.) reviewed for minimum for square footage per resident. Resident rooms A1 through A11, B12 through B23, C24 through C33, D34 through D40, E41 through E46 did not have a minimum of 80 square feet per resident. This deficient practice could affect residents residing in rooms could result in inadequate space to provide care and resident dissatisfaction with the environment.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on rights of the resident training for 1 of 28 employees (CNA C) reviewed for training. The facility failed to ensure rights of the resident training was provided to CNA C annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 1 of 1 facilities reviewed for nursing services. The daily staff posting was not updated on 5/18/25. This failure could result in residents and visitors not knowing how many staff were providing services to the residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision , The facility failed to supervise Resident #1 who eloped from the facility on 09/07/24 through an unlocked door and sustained a fall with no injury in the course of the elopement. An Immediate Jeopardy (IJ) was identified as past non-compliance on 04/24/25. The non-compliance began on 09/07/24 and ended on 09/09/24. The facility had corrected the non-compliance before the survey began on 04/23/25. This deficient practice could place residents including Resident #1, who were elopement risks, at-risk of harm, serious injury, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 5 of 5 residents (Resident #38, #11, #55, #17, and #48) reviewed for indwelling urinary catheter care, in that: 1. Resident #38's indwelling urinary catheter drainage bag was touching the floor. 2. The facility failed to ensure Resident #11 was provided proper catheter care. 3. Resident #55's indwelling urinary catheter drainage bag was touching the floor. 4. Resident #17's indwelling urinary catheter drainage bag and catheter tubing was touching the floor. 5. Resident #48 indwelling urinary catheter drainage bag and catheter tubing was touching the floor. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure 3 of 3 Nurses' Aides (NA E, NA F, & NA G) were not working in the facility longer than four months without having completed a competency evaluation program. The facility failed to ensure NA E, NA F, and NA G became certified within four months of hire as full-time staff. This deficient practice place residents at risk for receiving care from an individual whose skill level was not known.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 1 of 2 Medication Aides and 1 of 1 housekeeper reviewed for infection control, in that: 1. The facility failed to ensure Med Aide C utilized appropriate hand hygiene and infection control principles. Med Aide C did not perform hand hygiene between glove changes, did not sanitize the blood pressure cuff between residents and did not use proper PPE when providing services to residents on contact isolation for Residents #23, Resident #17, and Resident #35. 2. The facility failed to ensure Housekeeper N performed proper hygiene after cleaning Resident #23's and Resident #51's room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 1 of 24 residents (Resident #34) reviewed for resident rights. The facility failed to provide Resident #34's Responsible Party with the benefits, risks, and options available after a psychiatrist recommendation to discontinue the Ativan/Benadryl/Haldol Gel on 02/27/2024. This deficient practice could place residents at risk of receiving medications without their responsible party's risk prior knowledge or consent.

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 time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Residents #56) reviewed for comprehensive care plans in that: The facility failed to update a plan of care to address Resident #56's current use of oxygen. The care plan did not reflect Resident #56's self administration of his own oxygen. This deficient practice could place residents at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #55) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #55. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observations and interviews, the facility failed to ensure all facility dumpsters were equipped with a drain plug. 2 of the 3 facility dumpsters lacked a drain plug. This failure posed a sanitary and safety hazard that could result in water accumulating in the dumpsters and in the attraction of vermin from standing water.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain medical records on each resident that were accurately documented for 1 of 8 residents (Residents #213) reviewed for accurate medical records in that: The facility accurately documented Resident #213 mobility status on an admission assessment for elopement risk. This deficient practice could affect residents who have medical records and could result in misinformation about professional care provided.

Inspectors wroteBased on interviews and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format for 11 of 91 days in Fiscal Year Quarter 1 of 2024. Long-term care facilities must 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. The facility failed to submit staffing information to CMS for 11 of 91 days in Fiscal Year Quarter 1 of 2024. This deficient practice could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on record review and interview, the facility failed to include as part of its QAPI program, mandatory training that outlined and informed staff of the elements and goals of the facility's QAPI program, for 3 of the 16 staff members (LVN H, LVN I, CNA J) reviewed for mandatory training. Three staff members (LVN H, LVN I, and CNA J) reviewed for mandatory training had not received training regarding the facility's QAA-QAPI program. This deficient practice could place residents at risk of receiving inadequate care from staff who are unfamiliar with the facility's QAPI program.

Inspectors wroteBased on record review and interview, the facility failed to ensure all staff received training in compliance and ethics for 5 of the 16 staff members (the DON, LVN H, LVN I, CNA J, and RN K) reviewed for mandatory training. Five staff members (the DON, LVN H, LVN I, CNA J, and RN K) reviewed for mandatory training had not received training regarding compliance and ethics. This failure could place residents at risk of receiving inadequate care from staff who are uneducated on compliance and ethics.

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse neglect for 3 of 5 Residents (Residents 1, 2 and 3) whose records were reviewed for abuse and neglect. 1. The ADM reported the Resident to Resident altercation involving Resident #1 and Resident #2 about 4 hours after he learned about the incident. 2. The ADM reported an allegation of Resident Neglect after 4 hours after the incident took place. Resident #3 fell and sustained a fractured nose. These deficient practices could affect any Resident and contribute to abuse and neglect. 1. Review of Resident #1's face sheet, 2/24/24, revealed he was admitted to the facility on [DATE], with diagnoses including Dementia with agitation and Cognitive Communication Deficit. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect are reported immediately, but not later than 2 hours after the allegation is made for 3 of 5 Residents (Residents 1, 2 and 3) whose records were reviewed for abuse and neglect. 1. The ADM reported the Resident to Resident altercation involving Resident #1 and Resident #2 about 4 hours after he learned about the incident. 2. The ADM reported an allegation of Resident Neglect after 4 hours after the incident took place. Resident #3 fell and sustained a fractured nose. These deficient practices could affect any Resident and contribute to abuse and neglect. Review of facility policy, Abuse/Neglect revised 3/29/18, read: The facility will provide and promote the protection of resident rights. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received timely treatment and care that was eventually diagnosed with a laceration to the left foot. On 7/28/23, Resident #1 was found to have blood on her left foot when transferring to bed around 4 PM by NA AC. NA AD was aware of the injury prior to the end of her shift at 2 PM but did not report to a charge nurse. Resident #1 was left without care to her foot from the time NA AD noticed it bleeding (time undetermined) until 4 PM when NA AC noticed the foot bleeding. Resident #1 was sent to the hospital and was found to have a fracture of the fifth toe proximal phalanx. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all nursing staff have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 of 4 residents (Residents #1 and #3) reviewed for reportable incidents. The facility failed to complete in-service training to all direct care staff after four reportable incidents occurred involving Resident #1 and #3. Resident #1 had a fractured 5th toe. Resident #3 had a fall and hit his head after an improper mechanical transfer. This deficient practice could place residents at risk of being cared for by insufficiently trained staff following incidents that resulted in serious injury and risk of death.

Inspectors wroteBased on record review and interview, the facility failed to thoroughly investigate all alleged violations of resident abuse, neglect, exploitation, or mistreatment for 3 of 16 Facility Reported Incidents (#440095, #449979, #471822) reviewed for reporting allegations. The facility failed to thoroughly investigate: -An incident (#440095) when Resident #1 sustained a foot laceration during a shower and was not reported to nursing staff for at least two hours. -An incident (#449979) when Resident #4 complained of knee pain to which a right knee fracture was discovered at the hospital. -An incident (#471822) when an unoccupied shower room caught flame in the facility due to an electrical fire. This deficient practice placed residents at risk of abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on record review and interview, the facility failed to provide an environment that is free from accident hazards over which the facility has control and provide supervision and assistive devices to each resident to prevent avoidable accidents to prevent accidents, for 1 of 19 residents (Resident #3) reviewed for accident hazards and supervision. Resident #3 fell to the ground during a mechanical lift transfer. This deficient practice placed residents at risk for accidents and injury.

Inspectors wroteBased on record review and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 Physical Environment reportable incidents (#427073). The facility failed to complete a fire watch from 10:00 PM on 05/30/2023 through 8:00 AM 05/31/2023 while the fire alert system was offline. This deficient practice could place residents at risk of encountering fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the current nurse staffing data for 1 of 1 facility. The nurse staffing data on entrance on 02/06/2024 was for 01/29/2024. This deficient practice could place residents at risk by not providing adequate staffing information for the residents, staff, and visitors to ensure that resident care needs are met.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the facility has an active (engaged and involved) governing body that is responsible for establishing and implementing policies regarding the management of the facility for 1 of 1 facility. The governing body did not appoint an administrator who was actively engaged in establishing and implementing policies regarding the management of the facility by not involving himself in the investigations and in-servicing of staff following incidents occurring at the facility. This deficient practice could result in the facility not being managed in a responsible manner, which could affect the health and safety of all residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure a MDS assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 2 of 24 residents (Residents #31 and #61) reviewed for transmitting assessments, in that: 1. Resident #4's discharge MDS assessment was not completed and transmitted within 14 days of completion. 2. Resident #40's discharge MDS assessment was not completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.