Focused Care at Sherman

Inspectors wroteBased on observations and interviews the facility failed to ensure reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for the bedrooms of 1 of (Resident #1) 5 resident rooms reviewed for resident call systems. The facility failed to ensure the call lights in the rooms were within reach for Resident #1, making it inaccessible if the resident needed assistance. This failure could place residents at risk of being unable to have a means of directly contacting caregivers.

Inspectors wroteBased on interview and record reviews, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of all the facility's resident population in accordance with the facility dietary staff. The facility failed to ensure there were sufficient kitchen staff to timely carry out the functions of lunch services on 07/17/26. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents and/or hazards as possible for 1 of 6 residents (Resident #1) reviewed for supervision and accident hazards. The facility failed to ensure Resident #1 had adequate supervision when she failed to return inside the building following a smoke break on [DATE] at approximately 7:00 p.m. The facility failed to realize Resident #1 was not in the building until approximately 8:30 p.m. Resident #1 was found by the police on [DATE] at 8:47 p.m. deceased . The Resident was found less than 1/2 mile from the facility down a 20 - 30-foot creek embankment, tangled in tree roots and vines. An IJ was identified on [DATE]. The facility was notified and was given the IJ template on [DATE] at 2:51 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure full visual privacy for residents for 3 of 12 rooms (rooms [ROOM NUMBER]) reviewed for physical environment. The facility failed to ensure rooms [ROOM NUMBER] had privacy curtains installed to provide privacy for the residents. This failure placed residents at risk for no visual privacy during care which could cause decreased feelings of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity for 2 of 6 residents (Residents #1 and #) reviewed for resident rights. 1. The facility failed to ensure Resident #1 was not exposed while in a public area of the facility. 2. The facility failed to ensure Resident #2's urine collection bag had a privacy cover. These failures could cause the residents to become embarrassed and have lowered levels of self-esteem.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure resident call lights were answered in a reasonable time for three (Resident 1, Resident 2, and Resident 4) of three residents reviewed for resident call system. The facility failed to ensure Resident 1, Resident 2, and Resident 4's call lights were answered in a reasonable time to meet their needs with three of three residents being diagnosed with lack of coordination, muscle weakness, blindness, and wheelchair dependency for mobility. This failure could place all residents at risk of the inability to contact the nursing staff and obtain assistance when needed and maintain a dignified existence.

Inspectors wroteBased on observation, interview and record review the facility failed to the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect and exploitation for one (Resident #4) of 10 residents reviewed for abuse and neglect. 1. The facility failed to prevent Resident #4 from neglect and possible abuse when she was fearful of Resident #13 and remained in the room when she did not know who the resident was any longer. 2. The facility failed to investigate Resident #4's concerns and allegations. 3. LVN A, LVN B, the ADON and the DON failed to recognize aa possible allegation of abuse/neglect. 4. The facility failed to identify and intervene for Resident #4. 5. The facility failed to report and protect Resident #4 from additional psychosocial harm. An Immediate Jeopardy (IJ) was identified on 05/07/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 4 residents (Resident #115 and Resident #61) reviewed for accidents and hazards. 1. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #115 who was at medium risk for eloping from the facility. On 03/24/25, Resident #115 eloped out of the facility and the facility was not aware the resident eloped. Resident #115 was found in his wheelchair at the intersection of the service road off a major highway. The noncompliance was identified as PNC. The IJ began on 03/24/24 and ended on 03/25/24. The facility had corrected the noncompliance before the survey began. 2. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, and serve food in accordance with professional standards for food service safety for the facility's only kitchen in: 1. The facility failed to ensure food items in the facility refrigerator were dated or labeled. 2. The facility failed to ensure 2 dietary staff wore facial hair coverings while preparing and serving food dinner on 5/5/2025. 3. The facility failed to ensure the grease trap on the cooking griddle was cleaned and emptied daily. 4. The facility failed to ensure broken tiles from kitchen footboard were stored away from opened food. 5. The facility failed to ensure temperatures were taken of all cooked food before serving them to residents during lunch meal service on 05/6/25. 6. The facility failed to ensure some food items were not properly sealed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents right to be free from abuse and neglect for one (Resident #4) of 10 residents reviewed for abuse and neglect. The facility failed to protect Resident #4 (female resident) right to feel safe when she told the facility that she did not feel safe sharing a room with Resident #13 ( male resident). Resident # 4 told the facility that she did not want to be in a room with Resident #13. Resident #4 no longer remembered her relationship with Resident #13. The facility failed to address Resident #4's concerns and allowed her to continue to reside in the same room as Resident # 4. An Immediate Jeopardy (IJ) was identified on 05/07/25. The IJ template was provided to the facility on [DATE] at 1:43 PM. [...]

Inspectors wroteBased on observation, 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 resident needs for 7 (Resident #4, #13, #22, #28, #34, #165, #12) of 27 residents reviewed for care plans. 1. The facility failed to create and implement a care plan that reflected Resident #4's relationship and cohabitation with Resident #13. 2. The facility failed to create and implement a care plan that reflected Resident #13's relationship and cohabitation with Resident #4. 3. The facility failed to create and implement a care plan that reflected Resident #22's relationship with Resident #28. 4. The facility failed to create and implement a care plan that reflected Resident #28's relationship with Resident #22. 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to label and secure drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for the facility's one (hall 600 cart) of four medication carts reviewed for storage. 1. The facility failed to ensure Resident # 28's Lyumjev Insulin (Hormone) Pen, that was used on [DATE], was dated when opened. 2. The facility failed to ensure a vial of TB PPD, that was opened and used, was dated. 3. The facility failed to ensure 5 unopened and 1 opened vial of multi-dose flu vaccine and 3 unopened and 1 opened vial of multi-dose TB PPD was stored in a locked medication room or medication cart. [...]

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 3 of 17 residents (Resident #47, Resident # 28, and Resident #46) observed for infection control. 1. The facility failed to ensure LVN D performed hand hygiene before and after performing Resident #47's fingerstick blood sugar on 05/06/25 and failed to perform hand hygiene after cleaning the soiled glucometer. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure an effective pest control program was implemented so the facility is free of pests and rodents for one of twenty-four residents (Resident #2), the facility's only kitchen, the facility's only nurses' station, and one hall (100 hall) of five halls reviewed for pest control. 1. The facility failed to effectively treat Resident #2's room for gnats. 2. The facility failed to keep an effective pest control program so that the facility was free of gnats in the Kitchen. 3. The facility failed to ensure one hallway (100 hall) of 5 hallways where residents' rooms were located, were free of gnats. 4. The facility failed to ensure the nurses station was free from gnats. [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) to avoid duplicative testing and effort for one (Resident #9) of 2 residents reviewed for PASARR. The facility failed to refer Resident #12 to the state authority for potential mental illness trigger by submitting a corrected PASARR evaluation after the addition of a mental health diagnosis. This failure could affect the residents who had a documented psychiatric diagnosis by placing them at risk for not receiving needed treatment and services.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a baseline care plan for each resident that included instructions needed to provide effective and person-centered care for the resident that met professional standards of care within 48 hours of the resident's admission for one of two (Resident #57) residents reviewed for baseline care plans. The facility failed to complete a baseline care plan for Resident #57. This failure could place newly admitted residents at risk of not receiving effective and person-centered care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #12) of six residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #12's contracture to her left hand upon discharge from therapy services. These failures could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of six residents (Resident #8, and Resident #28) reviewed for pharmacy services. 1. The facility failed to ensure LVN B followed the manufacturer's instructions to prime the Insulin Apart (Novolog) Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #8. 2. The facility failed to ensure LVN D followed the manufacturer's instructions to prime the Lyumjev Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #28. These failures placed residents at risk of not receiving full dosage of medication.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and hazards. The facility failed to ensure adequate supervision and put measures in place to prevent Resident #1 who was at risk for eloping from the facility. Resident #1 had history of confusion, exit seeking behavior and wandering behavior. On 12/20/24, Resident #1 eloped out of the facility and the facility was not aware the resident eloped. Resident #1 was walking the streets about 3 blocks away from the facility in a residential area. The noncompliance was identified as PNC. The IJ began on 12/20/24 and ended on 12/26/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse for two (Resident #2 and an unknown Resident) of four residents reviewed for abuse. The facility did not implement their policy on reporting abuse to state agency for a resident-to-resident altercation that occurred on 12/13/24 between Resident #2 and an unknown Resident. This deficient practice could place residents at risk for abuse, neglect, and not having their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 2 (Medication Cart #1 and Medication Cart #2) of 2 medication carts observed for medication storage, in that: The facility failed to ensure controlled medications in unsecure bubble packaging cards were immediately removed from Medication Cart #1 and Medication Cart #2. These failures could place residents at risk of not having the medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication. Findings Included: During an observation and record review of medication cart #1 on 02/15/25 at 2:09 PM revealed a pill bubble packaging card filled with Tramadol 50 mg tablets (controlled medication used to treat insomnia [trouble sleeping]). [...]

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 5 residents (Resident #1) reviewed for misappropriation of resident property. RN A used Resident #1's prescribed Fentanyl (an opioid pain medicine that is used to treat moderate to severe chronic pain around the clock) 100 mcg 72-hour transdermal (skin) patch for personal recreational use on 02/12/25. This failure placed residents at risk of not receiving timely pain management care which could result in prolonged pain and diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 5 residents reviewed for quality of care, in that: The facility failed to monitor, treat, and reassess a wound to Resident #1's lower back. LVN A documented that Resident #1 had a pressure, venous, arterial, diabetic, or surgical wound (no location, no description disclosed) in a weekly skin assessment on 05/27/24 and 06/03/24 but did not notify the WCN. On 06/06/24, RCP B informed the WCN about an open area on Resident #1's lower back (WCN identified area as the very bottom of spine area - tailbone). [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician and responsible party when there was a significant change in the physical status for three of six residents (Resident Residents#15, #174, #71) reviewed for notification of changes. 1. Treatment Nurse and DON failed to notify Resident #15's Primary Physician when the wound care consultant had stopped seeing the resident on a weekly basis and failed to notify the Physician in a change of condition of the wounds. 2. LVN J failed to notify the Physician for wound care orders when Resident #15 re-admitted to the facility on [DATE]. 2. RN EE failed to notify the Physician and responsible party on 01/25/24 when Resident #174 developed a wound on her buttocks. 3. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to protect a resident's right to be free from abuse for 4 (Residents #7, #13, #49 and #325) of 12 residents reviewed for resident abuse. 1. The facility failed to ensure Resident #325 was free from physical abuse by CNA O on [DATE] 2. The facility failed to ensure Resident #49 was free from physical abuse by CNA O on [DATE]. 3. The facility failed to ensure Resident #7 was free from physical abuse by CNA O. 4. The facility failed to ensure Resident #13 was free from physical abuse by RN G on [DATE]. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 6:10 PM. While the IJ was removed on [DATE] at 7:00 PM, the facility remained out of compliance at actual harm with a scope identified as pattern. These failures placed residents at risk for serious injuries, abuse, and serious harm.

Inspectors wroteBased on observations, interview and record review, the failed to implement their written abuse prevention policy and thoroughly investigate abuse allegations for three (Residents #7, #325 and #49) of nine residents reviewed for resident abuse. 1. The Administrator and DON failed to follow their abuse policy by reporting the allegations of physical abuse of Resident #325, by alleged perpetrator, CNA O, to HHSC within 2 hours after becoming aware of the incident on [DATE] and to thoroughly investigate the allegation for Resident #325. The facility failed to ensure that CNA O was suspended immediately pending investigation for the physical abuse allegation of Resident #325. 2. The Administrator failed to follow their abuse policy and thoroughly investigating the allegation of physical abuse for Resident #49. 3. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure based on the comprehensive assessment of a resident the resident with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three of four (Residents #15, #174 and #71) residents reviewed for pressure ulcer care. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial wellbeing for 12 (Residents #4, #23, #35, #36, #41, #52 and five residents in confidential group interview) of 12 residents reviewed for staffing concerns. 1. The facility failed to ensure there were sufficient staff to ensure Resident #35 and #23 received 8 AM medications on time on 03/10/24. 2. The facility failed to ensure there was sufficient staff available to provide timely incontinent care for Resident #4 on 03/10/24. 3. The facility failed to ensure residents received showers on their shower days due to staffing issues. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to employ sufficient staff with appropriate competencies and skill sets to carry out the functions of the food and nutrition service for 1 of 1 facility kitchen reviewed for food and nutrition services. 1. The facility failed to have a qualified Dietary Manager who was full-time at facility. 2. The facility failed to ensure Dietary [NAME] met the required qualifications, the [NAME] did not have a food handling management certificate within 30 days of hire. This failure could place residents at risk for the spread of foodborne illness and negative impacts to their nutrition and health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation in that: On 3/10/2024, the facility failed to label and date 6 frozen tubes of raw ground beef, a box of frozen fried catfish, container of vegetable soup, container of ketchup, and container of refried beans, use appropriate hand hygiene practices, and failed to ensure proper food temperatures of ground beef puree and vegetable puree. These failures could place residents at risk for food contamination and food-borne illness and impact the health and nutrition of residents.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs and preferences for two (Residents #45 and #69) of sixteen residents reviewed for call lights. 1. Facility failed to ensure Resident #45's call button was within reach of Resident #45 while he was lying in bed. 2. Facility failed to ensure Resident #69's call button was within reach of Resident #69 while he was lying in bed. These failures could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident has a right to a safe, clean, comfortable and homelike environment for 9 (Residents #1, #5, #20, #21, #39, #41, #59, #67, #69) of 24 residents reviewed for safe and sanitary environment. 1. The facility failed to ensure Resident #20, #21, #41 and #59 had bed sheets in good condition without holes in them. 2. The facility failed to ensure Resident #39's curtain was without food stains. 3. The facility failed to ensure sheet rock behind toilet was in good condition not exposing pipes in Resident #69's bathroom. 4. The facility failed to ensure Resident #67's room had a curtain over the window. The facility failed to ensure Resident #67's bathroom had a toilet paper holder, a mirror, and sheet rock in bathroom wall did not expose pipes. 5. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 9 (Resident #4, Resident #26, Resident #16, Resident #2, Resident #36, Resident #41, Resident #52, Resident #5, Resident #47) of 24 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #4, who required extensive assistance, was provided with timely incontinence care on 03/10/24 from 6:30 a.m. to 3:15 p.m. 2- Resident #26 had her fingernails cleaned and trimmed. 3- Resident #16 was shaved and not having facial hair. 4- Resident #2 was shaved and not having facial hair. 5- Residents #36, #41 and #52 received showers on shower days. 6- Resident #5 her fingernails cleaned and teeth brushed. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide residents with an ongoing program of activities for 5 out of 5 residents (Resident #67, #46, #48, #70 and #5) reviewed for activities. The facility did not provide routine activities for Residents #67, #46, #48, #70 and #5. The failure could affect residents by placing them at risk for depression, boredom, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two of four residents (Residents #14 and Resident # 5) reviewed for pharmacy services in that- 1. RN G failed to follow the manufacturer's instructions to prime the Lispro Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #14. 2. RN D failed to follow the manufacturer's instructions to prime the Novolog Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #5. These failures placed residents at risk of not receiving full dosage of medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 6 residents (Resident #35, Resident #23, Resident #5, Resident #51, Resident #15, and Resident #45) of 8 observed for infection control. The facility failed to ensure: 1. MA F sanitized the blood pressure cuff between uses on Resident #35 and Resident # 23 and performed hand hygiene after performing blood pressure checks. 2. RN D prevented cross contamination of Resident #5's insulin and the medication cart when she dropped the insulin pen cap onto the floor, removed her gloves after administering Resident #5's insulin and leaving Resident #5's room and opening the medication cart, retuning Resident #5's box containing the resident's glucometer and insulin pen. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to allow the resident to obtain a copy of the medical records upon request and within 2 working days advance notice to the facility for 1 Resident (#227) of 24 sampled residents. The facility failed to provide a copy of Resident #227's medical records upon request by the resident's representative. The deficient practice could place residents at risk of contributing to a delay in the due legal process for residents and not having continuity of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary care and services to attain or maintain the highest, practicable physical, mental and psychosocial well-being in accordance with the comprehensive assessment and plan of care for one of four (Resident #51) residents reviewed for wound care. RN D failed to provide Resident #51 her prescribed wound care on 03/09/24. This failure could place residents at risk for a decline in the resident's condition, increased risk of infection and decline in wound healing. Findings Included: Review of Resident #51's Quarterly MDS assessment dated 12/2924 reflected a [AGE] year-old female admitted to the facility on [DATE]. Resident was cognitively intact with a BIMS of 14. [...]

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 one (Resident #45) of two residents reviewed for incontinence care. The facility failed to ensure RN D provided appropriate perineal care for Resident # 45 after an incontinent episode when she failed to clean the resident's scrotum, and penis. This failure could place residents at risk for the development and/or worsening of urinary tract infections and skin breakdown.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was not 5% or greater. The facility had a medication error rate of 6.45%, based on 2 errors of 31 opportunities, which involved two of four residents (Residents #35 and #23) and one of three staff observed during medication administration for medication errors in that-. 1. MA F failed to administer Resident #35's Pantoprazole 40 mg on 03/10/24 as ordered by the physician. 2. MA F failed to administer Resident #23's Omeprazole 20 mg on 03/10/24 as ordered by the physician. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observation, interview and record review the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 1 of 8 residents (Residents #18) reviewed for dental services. The facility failed to provide timely dental services for Resident #18 and follow up on dental referral. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on observations, interview and record review the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure refrigerator item in walk -in refrigerator was labeled, dated and sealed. 2. The facility failed to ensure black refrigerator unit with freezer on top and drink cooler freezer had thermometers. The facility failed to document temperatures. The facility failed to ensure cleanliness of drink cooler freezer. 3. The facility failed to ensure the Dietary Manager and Food Service Manager E washed their hands when touching PPE and changing gloves during lunch preparation on 02/08/23. 4. The facility failed to ensure hamburger patties' food temperature was taken after cooked and before served to residents for lunch on 02/08/23. [...]

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure residents received services in the facility with reasonable accommodation of needs and preferences for three (Residents #26, #4 and #5) of nine residents reviewed for call lights. 1. Facility failed to ensure Resident #26's call button was within reach of Resident #26 while she was lying in bed. 2. Facility failed to ensure Resident #4's call button was within reach of Resident #4 while she was lying in bed. 3. Facility failed to ensure Resident #5's call button was within reach of Resident #5 while she was lying in bed. These failures could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice and the residents' goals and preferences for three (Residents #47, #48 and #230) of five residents reviewed for oxygen therapy. 1. The facility failed to ensure there was a process in place to ensure there was an adequate amount of portable oxygen in the facility to meet the needs and preferences of residents who were on oxygen therapy. The administration did not maintain a reserve of portable oxygen tanks for residents to use as needed. 2. The Administration did not contact the Oxygen Vendor timely to ensure a delivery of portable oxygen tanks would be received before running out of portable oxygen tanks. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for one (Dietary Manager) of three dietary staff reviewed for qualifications. The facility failed to employ a qualified Dietary Manager. This failure could place the residents at risk of not being provided a nutritional well-balanced diet and not have their dietary needs identified and addressed.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two (Residents #71 and Resident #62) of eighteen residents reviewed for comprehensive care plans. 1. Resident #71's care plan failed to address interventions to prevent complications related to his indwelling urinary catheter and his G-tube. 2. Resident # 62's care plan failed to address his hospice election and failed to identify services that were provided by the hospice. These failures placed residents at risk of not receiving individualized care and services to meet their needs and interventions to prevent complications related to each individuals identified concerns.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one (Residents #71) of one resident reviewed for feeding tubes. The ADON failed to check placement of Resident #71's G-Tube by checking for gastric residual prior to administering the resident's medications. This failure could affect residents by placing them at risk of obstruction of the G-tube, nausea, vomiting and potential for aspiration and discomfort.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for two (Residents #4 and #5) of 10 residents reviewed for resident call system in that: The facility failed to ensure Resident # 4 and Resident # 5 call light outside the resident door was working properly. Resident # 4 and Resident # 5 resided in the same room. This failure could place residents at risk for delay in assistance and decreased quality of life, self-worth, and dignity.