Focused Care at Mount Pleasant

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 5 residents (Resident #1) reviewed for infection control. The facility failed to ensure the ADON applied enhanced barrier precautions when she performed a skin assessment and provided incontinent care to Resident #1 on 5/18/2026 at 3:00 PM.The facility failed to ensure the CNA applied enhanced barrier precautions while assisting the ADON with positioning and holding Resident #1 on 5/18/2026 at 3:00 PM.These failures could place residents at risk of cross-contamination and infections leading to illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, sanitary, comfortable, and homelike environment for 3 of 7 resident rooms and 1 of 2 hallways reviewed for environment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 6 residents reviewed for misappropriation of resident property. (Resident #1) The facility to failed keep Resident #1 free of misappropriation of property when RN A took a discontinued medication, 60 tablets of Meloxicam 7.5 milligrams, from the facility. This failure could place residents at risk for decreased quality of life, misappropriation of property, and dignity. Findings Included: Record review of face sheet dated 01/13/26 indicated Resident #1 was [AGE] years old and was initially admitted to the facility on [DATE] with diagnoses of senile degeneration of the brain (significant age-related cognitive decline), difficulty in walking, and a cognitive communication deficit. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights for 3 of 16 (Resident #4, Resident #5, and Resident #6) residents reviewed for care plans, The facility failed to ensure Resident #4's pressure ulcer to her buttock was care planned from her re-admission on [DATE] until 11/11/25. The facility failed to ensure Resident #5's wander guard status was properly care planned with the care plan indicating Resident #5 had a wander guard in place and observations and interviews indicating Resident #5 did not have a wander guard. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 6 (Resident #1) residents reviewed for quality of care. The facility failed to ensure Resident #1 had a skin assessment performed weekly on the weeks of 10/6/25, 10/13/25, 10/20/25, and 10/27/25 per facility policy. These failures could result in skin issues on residents being missed, skin issues deteriorating without being monitored, and decreased quality of life. Findings Included: 1. [...]

Inspectors wroteBased on observation, interview 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 promotes maintenance or enhancement of his or her quality of life for 1 of 16 (Resident #2) residents review for dignity and respect. The facility failed ensure Resident #2 was treated with dignity and respect by LVN A on 11/12/25 when LVN A told Resident #2 to sit his ass down. These failures could place residents at risk of a diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interview and record review the facility failed to complete an accurate MDS assessment to reflect residents' status for 1 of 16 residents reviewed for assessments. (Resident #4) The facility failed to ensure Resident #4's MDS dated [DATE] documented the presence of a pressure ulcer that she re-admitted to the facility with on 10/16/25. This failure could place residents at risk for inaccurate assessments and not receiving needed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 residents (Resident #1) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #1's Foley catheter drainage bag was kept off the floor on 10/21/25. These failures could place residents at risk for urinary tract infections, injuries, and a decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure in accordance with accepted standards of practices, the medical records on each resident were accurately documented for 2 of 16 residents (Resident #4 and Resident #7) reviewed for accurate medical records. The facility failed to ensure Resident #4's wound assessment completed on 11/7/25 by the Treatment Nurse accurately reflected her pressure ulcer was worsening as the Wound Care NP had documented on 11/7/25. The facility failed to ensure Resident #7's wound assessment completed on 11/7/25 by the Treatment Nurse accurately reflected her pressure ulcer was worsening as the Wound Care NP had documented on 11/7/25. These failures could place residents receiving wound care at risk for confusion on whether a wound is improving or worsening.

Inspectors wroteBased on observation, record review, and interview the facility failed to have an ongoing and effective pest control program for 3 of 7 resident rooms reviewed for pest control (Resident #1, Resident #2 and Resident #3.) The facility did not have an effective pest control program to eradicate the cockroaches in the facility. The facility failure placed residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.1. The facility failed to ensure all food items were labeled and dated in Refrigerator #1.2. The facility ensure that wall in the pantry was in good repair. 3. The facility failed to ensure that the pantry was free of rotting food.4. The facility failed to ensure that a scoop for the sugar bin was properly stored. 5. The facility failed to ensure the ceiling under the air conditioner duct was in good repair.6. The facility failed to ensure that all air conditioner vents were clean and free of condensation. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observation and interview the facility failed to maintain all mechanical and electrical equipment in safe operating condition for 1 of 1 kitchen reviewed for safe operating condition. The facility failed to ensure Freezer #2 maintained a safe storage temperature and not allow food items to thaw. This failure poses a risk of essential kitchen equipment malfunctions causing foods to be held at an unsafe temperature and cause food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 5 of 17 residents (Resident #3, Resident #24, Resident #39, Resident #48, and Resident #119) and 4 anonymous residents reviewed for palatable food. 1. The facility failed to ensure residents received food that tasted good. 2. The facility failed to ensure residents did not receive cold food. 3. The facility failed to ensure residents received preferred portion sizes. These failures could place residents at risk of weight loss, altered nutritional status and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 2 of 20 resident's (Resident #7 and Resident #37) reviewed for a homelike environment.1. The facility failed to ensure Resident #7's wall was free from peeling paint at the head of her bed with approximately 4 different areas measuring approximately 1-2 inches wide and 2-3 inches long.2. The facility failed to ensure Resident #7's wall was free from peeling paint by her pillow that measured approximately 6-8 inches at the widest point and a foot long at the longest point.3. The facility failed to ensure Resident #7's air condition/heat unit was free from peeling paint and/or caulk around the unit leaving approximately half inch gaps around the top of the unit.4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 9 residents reviewed for respiratory care. (Resident #7 and Resident #26)1. The facility failed to ensure Resident #7's oxygen concentrator (takes air from the surroundings, extracts oxygen and filters it into purified oxygen for resident to breathe) air intake area (mouth of the oxygen concentrator bringing in the air that will be processed) was not covered in gray fuzzy dust-like and hair-like particles.2. The facility failed to ensure Resident #7 had an order and care plan for oxygen therapy.3. The facility failed to ensure Resident #26's oxygen concentrator air intake area was not covered in gray fuzzy dust-like and hair-like particles. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nurse aides were able to demonstrate competency in skills and necessary techniques to care for resident's needs, as identified through resident assessments and described in the plan of care for 1 of 2 RCPs (RCP E) reviewed for nurse aide competencies. The facility failed to ensure RCP E was competent in performing a safe mechanical lift (machine used to lift and transfer a resident from one surface to another, such as from chair to bed/bed to chair) transfer on Resident #2 when RCP E did not place the legs of the mechanical lift in the wide position when lowering or transferring the resident and did not lock the lift wheels while lifting or lowering the resident. This failure could place residents at an increased and unnecessary risk of injury.

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 4 residents reviewed for enhanced barrier precautions (Resident #121) infection control practices. The facility failed to ensure RN C donned (put on) a gown prior administering medications and feeding to Resident #121 via g-tube. Resident #121 was on enhanced barrier precautions. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their own established smoking policy for 1 of 9 residents reviewed for smoking. (Resident #37)The facility failed to ensure Resident #37 followed the smoking policy and did not have smoking supplies (cigarettes and lighter) at his bedside. This failure could place residents at risk for injury or harm.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse for 1 of 8 residents (Resident's #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from physical abuse on 11/21/24, when Resident #2 hit Resident #1 numerous times with the foot pedal of a wheelchair. The physical assault on Resident #1 resulted in worsening of a brain bleed with a midline shift (increased pressure in the brain). The noncompliance was identified as PNC. The immediate jeopardy (IJ) began on 11/21/24 and ended on 11/21/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of serious injury, physical harm, serious impairment, or death.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent incident and accidents for 2 of 8 residents (Resident #1 and Resident #3) reviewed for accident hazards and supervision. 1. The facility failed to ensure adequate supervision was provided to prevent a resident-to-resident physical altercation on 11/21/24. Resident #2 repeatedly hit Resident #1 with a metal wheelchair pedal, which resulted in worsening of a brain bleed with a midline shift (increased pressure in the brain). 2. The facility failed to ensure adequate supervision was provided to prevent Resident #3 from falling, which resulted in a nasal fracture on 06/02/25. An immediate jeopardy (IJ) was identified on 06/24/25 at 12:55 PM. [...]

Inspectors wroteBased on observation , 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 determine that drug records are in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 2 residents (Resident #12) reviewed for drug diversion. The facility failed to prevent the drug diversion of 55 tablets of Hydrocodone (Norco) (a combination medicine that is commonly taken for severe pain) for Resident #12 on 2/6/2025. This failure could place residents at risk for drug diversion of physician ordered medications which could result in residents not having medications/treatments available and a decline in health.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were free from abuse for 5 of 66 residents (Resident #1, #2, #3, #4, and #5) reviewed for resident abuse. The facility did not ensure Resident (Resident #1, #2, #3, #4, and #5) were free from abuse. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 8 (Resident #1) residents reviewed for abuse. The facility failed to protect Resident #1 from verbal and physical abuse from LVN A on 9/26/24 resulting in Resident #1 being pushed by LVN A and falling to the floor. The noncompliance was identified as PNC. The noncompliance began on 9/26/24 and ended on 9/27/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with personal privacy and confidentiality of his or her personal and medical records for 1 of 20 (Resident #40) residents reviewed for resident rights. 1. LVN A video recorded Resident #40 on [DATE] when he was in an emergent situation using her personal device and then shared the video with RN B on [DATE]. 2. RN B shared the [DATE] video recording with the ADON, and the BOM on [DATE]. 3. Resident #23 overheard LVN A having a telephone discussion on her personal cell phone of the video recording on [DATE] of Resident #40 while in a common area on her personal cell phone. 4. LVN A and RN B were in possession of the video recording on their personal devices from [DATE] - [DATE]. 5. RN B continued to have a screen shot of the video recording of Resident #40 on her personal cellular device on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure procedures were in place to document a resident's choice regarding CPR for 1 of 20 residents (Resident #114) reviewed for CPR. 1. The facility performed CPR on Resident #114 on [DATE], after failing to accurately assess Resident #114's representative's choice for DNR code status on or before admission. 2. The facility failed to have a system in place to ensure staff maintained accurate CPR certifications. The SW failed to accurately document Resident #1's code status on the social service assessment. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] . The IJ template was provide to the facility on [DATE] at 4:43 p.m. [...]

Inspectors wrote2. Record review of the face sheet, dated 05/24/2024, revealed Resident #30 was an [AGE] year-old male who admitted to the facility on [DATE] with diagnoses of anxiety disorder (mental illnesses that cause constant fear and worry) and neuropathy (numbness or tingling in hands or feet from damaged nerves). Record review of the comprehensive MDS assessment, dated 03/11/2024, revealed Resident #30 had clear speech and was understood by staff. The MDS revealed Resident #30 was able to understand others. The MDS revealed Resident #30 had a BIMS score of 7, which indicated severely impaired cognition. The MDS revealed Resident #30 was taking an antipsychotic and antianxiety medication during the last 7 days of the look-back period. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 4 of 20 residents (Residents #'s 13, 39, 44, and 59), reviewed for care plans. 1)The facility failed to revise and update Resident #13's comprehensive care to reflect his election of hospice services on 5/17/2024. 2)The facility failed to revise and update Resident #39's comprehensive care plan to reflect he was no longer residing on the secured unit as of 5/17/2024. 3)The facility failed to revise and update Resident #44's comprehensive care plan to reflect he was using oxygen continuously. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 73.08 %, based on 19 errors out of 26 opportunities, which involved 3 of 3 residents (Residents #14, #24 and #56) reviewed for medication administration. The facility failed to ensure Residents #14 and #24 medications were administered during the scheduled time. The facility did not ensure Resident #56 was given Famotidine 20 mg. The facility did not ensure Resident #56 Diclofenac Sodium 1% was applied to one extremity instead of both extremities. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 1 out of 1 kitchen reviewed for sufficient support personnel. The facility did not ensure the lunch meal on 05/20/2024, 05/21/2024, and 05/22/2024 were served on time. This failure could place residents at risks who consume food prepared in the kitchen at risk of foodborne illness.

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 safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated. 2. The juice machine spigot was free from a red gooey substance where the juice was dispersed. 3. Muffin pans were free from encrusted black colored grease buildup coating the entire outside and most of the inside surface. 4. The steam pans were stacked with water pooled in between them. 5. The microwave was clean and free of food debris. 6. The stove was clean and free of food debris. 7. Test strips (test strips used to measure the concentration of chemicals in sanitizing solution) were not expired. 8. Hair restraints worn. These failures could place residents at risk for foodborne illness.

Inspectors wrote2. Record review of a face sheet dated 5/22/2024 indicated Resident #44 was a [AGE] year-old male who admitted on [DATE] and readmitted on [DATE] with the diagnoses of Alzheimer's Disease (dementia, memory loss disease), and obstructive and reflux uropathy (blocked or backward flow of uine). Record review of a Significant Change MDS dated [DATE] indicated Resident #44 was usually understood, and usually understood others. The MDS indicated Resident #44's BIMS was a 7 indicating severe cognitive impairment. The MDS in section GG-Functional Abilities and Goals indicated Resident #44 was dependent of the staff to complete all of the effort of toileting. The MDS in section H-Bladder and Bowel H0100Resident #44 was indicated to have an indwelling catheter and in H0300 to have not rated due to the use of a Foley catheter. [...]

Inspectors wroteBased on interview and record review, the facility failed to establish a infection prevention and control program that includes antibiotic use protocol and a system to monitor antibiotic use for 1 of 4 residents and reviewed for antibiotic stewardship program. (Resident #11) The facility did not ensure Resident #11 was assessed using the established and accepted criteria to determine if her UTI met the criteria for antibiotic use. These failures could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility is free of pests and rodents for 1 of 3 units (the facility's main building to include the dining room, hallway, and room [ROOM NUMBER], 49, and 52). The facility did not maintain an effective pest control program to ensure the facility was free of flies in the main building dining room, hallway, and Resident Room's 48, 49, and 52. These findings could place residents at risk for an unsanitary environment and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 3 dining room (women's secure unit dining room) reviewed for resident rights. The facility did not ensure LVN O treated residents with dignity and respect by referring to them as feeders in the women's secure unit during lunch meal service. This failure could place residents at an increased risk of embarrassment, isolation, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to allow residents to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the family for 1 of 1 (Resident #44) resident reviewed for the right to access copies of records. The facility failed to provide medical records for Resident #44 to his attorney within two working days of a request on 11/27/2023 for them. This failure could place residents at risk by causing a negative health impact due to not having continuity of care.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 1 of 20 residents reviewed for advanced directives. (Resident #52) The facility failed to ensure Resident #52's code status was accurate and consistent with all records at the facility. This failure placed the residents at risk of not having their end of life wishes honored.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 2 locked units (men's secure unit dining room) observed for homelike environment. The facility failed to ensure residents did not receive meals on serving trays in the dining room during the lunch mealtimes. This failure could result in residents having poor self-esteem and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 4 residents reviewed for range of motion. (Resident #215) The facility did not ensure Resident #215 had a contracture prevention device in place for the treatment of his left hand, wrist, and elbow contracture. This failure could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 2 of 2 residents (Resident #13 and Resident #44) reviewed for indwelling urinary catheters and incontinent care. 1. The facility failed to ensure Resident #'s 13 and 44's urinary (foley) catheter was properly secured to his leg. 2. The facility failed to ensure Resident #44 was provided proper incontinent care and catheter care. This failure could place residents with urinary catheters at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 4 residents (Resident #44) reviewed for respiratory care. The facility failed to ensure Resident #44's oxygen was set at 2-3 liters per minute as prescribed by physician. These failures could place residents requiring respiratory care at risk for respiratory infections or complications.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 1 resident reviewed for dialysis services. (Resident #215) The facility failed to keep ongoing communication with the dialysis facility and did not ensure the post-dialysis assessments were completed for Resident #215. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 20 residents' (Resident #'s 38) reviewed for trauma-informed care. The facility did not ensure Resident #38 had a trauma screening that identified possible triggers when Resident #38 had a history of trauma. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 2 of 3 residents (Residents #14 and #24) reviewed for pharmacy services. The facility failed to ensure Residents #14 and #24 medications were administered during the scheduled time. This failure could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meal (breakfast) reviewed for menus. The facility failed to follow the breakfast menu for residents on 05/22/2024 . This failure could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.

Inspectors wroteBased on record review and interview the facility failed to ensure the arbitration agreement was explained in a form and manner, including a language the resident or representative understood for 1 of 4 residents reviewed for arbitration agreements. (Resident #44) The facility failed to ensure the binding arbitration agreement was fully understood and explained to Resident #44's responsible party, prior to signing it as part of the admission packet. This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #13) reviewed for hospice services. The facility failed to ensure coordination of care with Resident #13's hospice provider. These deficient practices could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately to local law enforcement for 1 of 12 (Resident #2) residents reviewed for abuse, neglect, and misappropriation. HK A withdrew money from Resident #2's bank account. The facility failed to report the misappropriation to the local police and failed to thoroughly investigate the allegation of misappropriation. This failure could place residents at risk of misappropriation.

Inspectors wroteBased on interview and record review the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 12 residents (Resident #1) reviewed for Quality of Care. LVN A did not document neurological checks were completed after Resident #1 had an unwitnessed fall on [DATE]. The facility failed to ensure neuro checks were completed as ordered. LVN A failed to document Resident #1's use of anticoagulants on the change in condition form given to emergency responders and the hospital when Resident #1 was sent to the hospital due to a change in his condition. These failures could place residents at risk of physical harm or infection.

Inspectors wroteBased on interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 1 of 5 residents reviewed for unnecessary medications. (Resident #5) The facility failed to ensure Resident #5 had behavior monitoring for with the use of anti-psychotic medications. These failures could place residents at risk for receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.

Inspectors wroteBased on observation, and interview the facility failed to provide a safe, clean, and comfortable environment for 4 of 4 restrooms reviewed. (Room #'s 1 and 3, 2, 5 and 7, and 6 and 8, and 2) The facility failed to ensure resident room #'s 1 and 3's restroom flooring was not discolored with black colored staining. The facility failed to ensure resident room [ROOM NUMBER]'s restroom flooring was not water stained and discolored, and the toilet caulking was brown and discolored. The toilet seat in room [ROOM NUMBER]'s restroom had worn areas with the wood material visible. The facility failed to ensure resident room #'s 5 and 7's restroom flooring appeared to have water damage and the caulking around the toilet was a brown and black color. The facility failed to ensure resident room #'s 6 and 8's restroom flooring was water damaged, torn, and coming unglued from the concrete floor. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure the resident had a right to reasonable accommodations of resident needs for 2 of 2 residents (Resident #'s 3 and 4) reviewed for accommodations of needs. The facility failed to have a bariatric shower chair available for showers for Resident #'s 3 and 4. This failure could place residents at risk for skin irritation, wounds, and a sense of loss of dignity.

Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 5 (Resident #2) residents reviewed for notification of change. The facility failed to notify Resident #2's physician when he continually refused his medications. These failures could result in residents with not receiving treatments, supplements, or medications to maintain health.

Inspectors wroteBased on observation, interview, and record review the facility failed to have evidence alleged violations were thoroughly investigated to prevent further abuse for 1 of 5 residents reviewed for neglect. (Resident #1). The facility failed to ensure a thorough investigation was conducted when Resident #1's family alleged Resident #1 was not provided care on 9/17/2023 from 10:43 p.m. to 5:27 a.m. on 9/18/2023. This failure placed residents at risk for further neglect of the provision of care.

Inspectors wroteBased on interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 4 residents reviewed for nutritional status (Resident #1). The facility failed to ensure Resident #1 did not have a significant weight loss in 30 days. This failure could place residents at risk for malnourishment, illness, skin breakdown, and decreased quality of life.

Inspectors wroteBased on observations, 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, mental and psychosocial needs that are identified in the comprehensive assessment for 2 of 5 residents (Resident #'s 3 and 4) reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #3 was scheduled a specialty vision appointment, a cardiology appointment, and a gastrologist appointment as ordered. The facility failed to ensure Resident #4 was scheduled a sleep study and an echocardiogram as ordered. These failures could place residents at risk for inadequate monitoring of their health status.

Inspectors wroteBased on observations, interviews, and record reviews 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 5 of 5 residents (Residents #1, #2, #3, #4 and #5) and 6 out of 11 nondedicated and contracted staff (MA A, CNA B, CNA F, CNA CC, Hospice Aide and X-ray Technician) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to report the COVID-19 outbreak to both the local health department and HHSC. 2. The facility failed to ensure facility staff had readily available access to appropriate PPE supplies when caring for Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible to prevent accidents for 2 of 6 locked doors (employee smoke door and exit door on the northeast hall) reviewed for accidents and hazards. The facility did not ensure the employee smoke door and the exit on the northeast hall remained locked with the alarm engaged. This failure could place residents at risk for injury from elopement to unsafe areas around the facility.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 2 (women's secured unit) medication carts reviewed for storage of medications. The facility did not ensure MA A kept the medication cart on the women's secured unit locked or within her line of site. This failure could place residents at risk for misuse of medication and overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 6 of 21 residents (Resident #2, Resident #7, Resident #29, Resident #44, Resident #54, and Resident #58) and 1 of 1 staff (CNA N) reviewed for resident rights. The facility failed to ensure Resident #2 was treated with dignity and respect when CNA H did not refrain from using his cell phone while assisting Resident #2 with dining. The facility failed to ensure Resident #29's catheter drainage bag was not visible from the hallway. The facility failed to ensure Resident #54, and Resident #58 were served lunch at the same time as the other residents at the table. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all allegations of abuse and neglect, had evidence that all alleged violations were thoroughly investigated, and failed to report the results of all investigations to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for 3 of 8 residents (Residents #8, #10, and #264) reviewed for investigating alleged violations of abuse and neglect. 1. Incident investigation regarding Resident #8's allegation of neglect did not have interviews, in-services, or witness statements, attached to the investigation. 2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to complete a comprehensive resident-centered assessment of each resident's cognitive, medical, and functional capacity in a timely manner for 4 of 21 residents (Resident's #9, #51, #164, and #165) reviewed for comprehensive assessments and timing. The facility failed to complete Resident #9, Resident #51, Resident #164, and Resident #165's admission MDS assessment within 14 days of admission. This failure could place residents at risk of not having their needs identified and met.

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, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 7 of 21 residents (Resident #13, Resident #26, Resident #51, Resident #53, Resident #54, Resident #57, and Resident #165) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #13 and Resident #26's contractures. The facility failed to care plan Resident #51's use of the psychotropic medication Risperdal (antipsychotic medication used to treat certain mental/mood disorders) and diagnosis of PTSD (Post-Traumatic Stress Disorder). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 5 of 6 residents reviewed for ADLs. (Resident #9, #11, #12, #44, and #58) 1. The facility failed to ensure Resident #9 received her scheduled showers and facial hair removal. 2. The facility failed to ensure Resident #11 was provided incontinent care and facial hair removal. 3. The facility failed to ensure Resident #12's hair was combed, and nails were cleaned and trimmed. 4. The facility failed to ensure Resident #44 was routinely showered. 5. The facility failed to ensure Resident #58 was routinely showered. These failures could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 3 of 3 residents reviewed for range of motion. (Resident's #8, #13, and #26) 1. The facility did not ensure Resident #8 had a contracture prevention device in place for the treatment of her right contracted hand. 2. The facility did not ensure Resident #13 had a contracture prevention device in place for the treatment of her right contracted knee, left contracted knee, and left contracted hand. 3. The facility did not ensure Resident #26 had interventions in place for his left contracted arm. This failure could place residents at risk for decrease in mobility and range of motion and contribute to worsening of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 3 residents (Residents #52, #11, and #22) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to residents' who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

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 safety in the facility's only kitchen. The facility failed to ensure: 1. Food items were dated and labeled. 2. Expired food item was discarded. 3. The microwave was clean and free of food debris. 4. Hair restraints were worn appropriately by dietary staff. 5. The deep fryer was free of grease build up. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure safe and sanitary storage of resident's food items for 3 of 3 residents reviewed for personal food safety. (Resident's #9, #22, and #26) The facility did not implement the personal food policy related to personal refrigerators for Resident's #9, #22, or #26. These failures could place the residents at risk for food borne illness.

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 and to help prevent the development and transmission of communicable diseases and infections for 6 of 6 staff (LVN A, LVN B, LVN E, CNA K, CNA V, and CNA X), 1 of 1 shower room (north hall shower room), and 1 of 1 facility reported incident reviewed for infection control. The facility failed to ensure the sharps containers located in the north hall shower room were emptied and not overfilled. The facility did not ensure LVN A performed hand hygiene between glove changes while administrating insulin (helps blood sugar enter the body's cell to be used for energy) to Resident #27. The facility did not ensure LVN B disinfected the wrist blood pressure monitor between Resident #19 and #33. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure residents have 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 and to choose the option he or she prefers for 1 of 5 residents reviewed for right to be informed. (Resident #30) The facility failed to ensure Resident #30 had signed psychotropic consent forms for Risperdal (antipsychotic) and buspirone (antianxiety). This failure could place residents at risk for treatment or services without informed consent.

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 changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #57 and #42) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Residents #57 and #42 were given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 3 shower rooms (north hall) and 1 of 22 rooms (room [ROOM NUMBER]) reviewed for a homelike environment. The facility failed to ensure the north hall shower room was clean. The facility failed to repair a missing tile on the wall in front of the toilet in room [ROOM NUMBER]'s bathroom, leaving a hole in the wall. The facility failed to repair a fallen tile on the wall inside of the bathroom by the doorframe in room [ROOM NUMBER], exposing the sheetrock and leaving the tile against the wall in upright position. This failure could place residents at risk for a diminished quality of life and a diminished clean well-kept environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 1 residents (Residents#52) reviewed for grievances. The facility did not ensure Residents #52's grievances related to protein bars was resolved. This failure could place resident at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on interview, and record review the facility failed to ensure the assessment accurately reflect the status of 1 of 24 residents reviewed for assessment accuracy (Resident #57). The facility failed to accurately reflect Resident #57's weight loss of 5% of more that was indicated on the MDS. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 1 of 3 residents (Resident #4) reviewed for baseline care plans. The facility failed to ensure Resident #4 had a baseline care plan completed within 48 hours of admission This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 2 of 2 residents (Resident #15 and Resident #165) reviewed for activities of daily living. The facility failed to assess Resident #15's and Resident #165's need for communication assistance to effectively communicate with staff. This failure could place residents at risk for decline and diminished quality of life.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #51) reviewed for accidents, hazards and supervision. The facility failed to ensure LVN C and the DON transferred Resident #51 appropriately with the use of a gait belt. This failure could place residents who require assistance with transfers at risk for falls, pain, and injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 2 residents (Resident #52 and Resident #33) reviewed for respiratory care. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #52. The facility failed to administer oxygen at 2 - 3 liters per minute via nasal cannula as prescribed by the physician and ensure the filter door vents were free of debris for Resident #33. This failure could place residents who receive respiratory care at risk for developing respiratory complications. Findings Included: Record review of Resident #52's face sheet dated 03/09/23 indicated he was a [AGE] year-old male that was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pain management was provided to residents who require such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 1 residents reviewed for pain management. (Resident #52) The facility failed to ensure Resident #52 had effective pain management by not making an appointment or attempting to schedule an appointment with pain management after resident was discharged from hospice care. This failure could place resident at risk for increased pain causing undo suffering.

Inspectors wroteBased on interviews and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 2 of 2 residents reviewed for dialysis services. (Residents #26 and Resident #44) The facility failed to keep ongoing communication with the dialysis facility for Resident #26 and Resident #44. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation and interview, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 20%, based on 5 errors out of 25 opportunities, which involved 1 of 4 residents (Resident #19) reviewed for medication administration. The facility failed to ensure Resident #19 received amlodipine besylate 10 mg, ASA 81 mg, doxazosin mesylate 4 mg, vitamin B12 1000 mcg, and vitamin D3 2000 IU between 6:00 a.m. and 8:00 a.m. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication carts (Nurse Northwest Hall) reviewed for storage of drugs. The facility failed to ensure Northwest Hall nurse cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 1 residents (Resident #165) reviewed for therapeutic diets. The facility failed to ensure Resident #165 received a pureed diet and honey thick liquids as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, choking, and aspiration (when food or drinks enter the lungs).

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices on each resident and accurately documented for 1 of 4 residents (Resident #19) reviewed for accuracy of medical records. The facility did not ensure Resident #19 ASA order had the medication dosage listed. This failure could place residents at risk of not receiving the correct medication dosage.

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 3 of 5 residents (Residents #53, #21, and #57) reviewed for immunizations. 1. The facility failed to ensure Resident #53's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. 2. The facility failed to ensure Resident #21's medical record contained evidence of education on the pneumococcal immunization when the vaccine was administered to the resident. The facility failed to ensure Resident #21's medical record contained evidence of education on the influenza vaccine when the vaccine was administered to the resident. 3. [...]