Forest Park Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for one (Residents #1) of 5 residents reviewed for resident rights. The facility failed to ensure CNA A did not leave her computer tablet unattended on a bedside table that was located on the 200 hall. It was unlocked and displayed Resident #1 was incontinent for bowel movements. This failure could place residents at risk of having their medical information disclosed by residents and visitors which could cause embarrassment, frustration, and feelings of decreased privacy, resulting in a decline in their health and psycho-social well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure within 14 days after the facility determined, or should have determined, that there had been a significant change assessment completed for the resident's mental condition for 1 (Resident #2) of 5 residents reviewed for resident assessments. The facility failed to ensure a comprehensive MDS significant change assessment was completed for Resident #2, after he made suicidal ideation statements on 05/07/26, 05/18/26 and 05/25/26, 06/03/26 and 06/22/26. This failure could place residents at risk of not getting all of their medical needs met, which could cause residents to harm themselves resulting in decreased health and psycho-social well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's assessments accurately reflected their statuses for 1 (Resident #2) of 5 residents reviewed for resident assessments. 1) The facility failed to ensure SW B correctly completed Resident #2's 05/07/26 MDS assessment. SW B did not review and capture his suicidal ideations in the prior 14 days. SW B failed to ask this resident if in the past 14 days did, he have suicidal ideations; subsequently Resident #2 made suicidal statements which were within 14 days of this assessment and not included in Section D.0500 (i).2) The facility failed to ensure SW B correctly completed Resident #2's 06/02/26 Quarterly MDS assessment. SW B did not review and capture his suicidal ideations. SW B failed to ask this resident if in the last 14 days did, he have suicidal ideations; [...]

Inspectors wroteBased on interviews and record reviews the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of 3 residents, reviewed for medications. The facility failed to ensure Resident #1's order for Wellbutrin 300 mg was not duplicated on the MAR.The facility failed to ensure the staff signed off on the MAR correctly. Staff signed off that they administered 600 mg when they only administered 300 mg. This failure placed residents at risk for medication related errors and medication overdose.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's 1 of 1 kitchen reviewed for food safety. The facility failed to ensure food items in the dry storage room were properly stored, sealed, and protected from exposure to air in accordance with professional food service standards. The facility failed to ensure food items in the walk-in refrigerator were properly stored, sealed, and protected from exposure to air in accordance with professional food service standards. The garbage receptacle at the #1 handwashing sink contained items other than paper towels. These failures could place residents at risk for food-borne illness, cross contamination, and infection. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility for 119 residents reviewed for pests, Gnats were observed in rooms and hallways on Hall A (first floor), Hall B, (secured unit), and Hall C (second floor), in the facility. This failure could place residents at risk of an increased exposure to pests and vector-borne diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for care plans:The facility failed to ensure Resident #1's comprehensive care plans reflected that she had refused her medications on and off for the past 2 months. This failure could affect residents by placing them at risk of not receiving care and services to meet their needs.

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 two (Resident #78, and #124) of four residents reviewed for infection control. The facility MA A failed to disinfect the blood pressure cuff in between vital sign checks for Resident #78, and Resident #124. The facility MA A failed to wash hands prior to eye drops administration to Resident #78. This failure could place residents at risk for spread of infection through cross-contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for one (Hall C Nurse Cart) of five medication carts reviewed. LVN A failed to ensure that Hall C nurse cart was not left unlocked and unattended with the keys still in the lock mechanism in between rooms [ROOM NUMBERS]. This failure placed residents at risk of having access to medications not ordered for them or more than recommended doses. Observation and interview on 02/03/26 at 3:48 PM, revealed a medication cart on C hall was left unlocked and unattended with the keys still in the lock mechanism in the middle of C hall between rooms [ROOM NUMBERS]. [...]

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 disease and infections for 1 (Resident #1) of 7 residents reviewed for infection control. 1. LVN B and CNA C failed to wear PPE gown during incontinence care for Resident #1 who was on Enhanced Barrier Precautions for G-tube and Wounds. 2. LVN B failed to change her gloves and failed to perform hand hygiene when she did not remove her dirty gloves after finishing incontinence care for Resident #1 before connecting her feeding tube back to the feeding. These failures could place residents at risk of infectious disease. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medications were secured and inaccessible to unauthorized staff and residents for one medication cart on the second floor reviewed for medication storage. The facility failed to ensure the 2nd floor medication cart was locked when unattended. This failure could place residents at risk for drug diversion, drug overdose, and accidental administration of medications to the wrong residents.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for supervision. The facility failed to provide adequate supervision for Resident #1 during a routine incontinent change which involved CNA A and CNA B which led to Resident #1 hitting their head on the bedside table. This failure could place residents at risk of injury.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide and document sufficient preparation and orientation of resident to ensure safe and orderly transfer or discharge from the facility and ensure the orientation was provided in a form and manner that the resident could understand for one (Resident #1) of three residents reviewed for discharge.1. On 09/26/2025, the facility failed to ensure Resident #1's post-discharge destination and continued care provider could meet Resident #1's needs. Resident #1 required medication management and supervision with activities of daily livings, which the shelter did not provide. 2. On 09/26/2025 the facility failed to ensure Resident #1 was admitted to the shelter, as Resident #1 was left standing in line. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident's environment remained as free of accident hazards as is possible and received adequate supervision and assistance for one (Resident #1) of five residents reviewed for Incident and accidents. 1. The facility failed to provide adequate supervision for Resident #1 to prevent her from having injuries and falls from 02/02/25 to 02/08/25; subsequently Resident #1 sustained a left wrist fracture of unknown origin on 02/02/25, fell on [DATE] sustained a lip bleed, found on the floor next to her bed on 02/07/25 and on 02/08/25 she had left sided facial bruising, a swollen chin, and dark reddish gums. She was later diagnosed at the hospital on [DATE] with a hematoma of her jaw and previously diagnosed left wrist fracture. 2. [...]

Inspectors wroteBased on 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 set forth at, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Resident #1) of five residents reviewed for care plans. The facility failed to ensure Resident #1's care plan addressed her combative behavior (aggressive and eager to fight or argue) as documented by RN Q on 01/26/25 and ADON F on 01/27/25. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for one (Resident #1) of five residents reviewed for injury of unknown origin reporting. The facility failed to ensure on 02/02/25 Resident #1's injury of unknown origin was reported to HHSC when the staff did not know why she had a swollen left wrist that was later diagnosed as fractured (broken). [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure In response to allegations of abuse, neglect, or mistreatment, have evidence that all alleged violations were thoroughly investigated to prevent further potential abuse, neglect, or mistreatment while the investigation was in progress. And report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident for one (Resident #1) of five residents reviewed for Abuse and Neglect. The facility failed to ensure on 02/02/25 Resident #1's injury of unknown origin was investigated and report sent to HHSC when the staff did know why she had a swollen left wrist that was later diagnosed as fractured (broken). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for one (Resident #2) of five residents reviewed for medications errors in that: The facility administered Clonidine to Resident #2 on multiple occasions outside of the ordered blood pressure parameters. This failure could place residents receiving blood pressure medications at risk for low blood pressure.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 5 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Hydrocodone-Acetaminophen, a medication to help with pain. This failure could place residents at risk for not receiving prescribed medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 5 residents (Resident #1) reviewed for accurate reconciliation of controlled medications. The facility failed to have an accurate reconciliation and accounting of all controlled medications for one resident (Resident #1) of five residents reviewed for accurate reconciliation of controlled medications. This failure could place residents receiving controlled medications at risk for a lack of availability of controlled medications or unnecessary interruptions in receiving controlled medication due to possible drug diversion.

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, in that: - The facility failed to ensure food items stored in walk-in cooler were labeled and dated. - The facility failed to ensure foods stored in the walk-in cooler were stored in a sanitary manner. - The facility failed to ensure foods stored in the walk-in freezer were labeled and dated. - The facility failed to ensure personal food items were not stored in the preparation cooler. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne 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 service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine was clean and free of mildew and lime. 2. The facility failed to discard open items stored in the refrigerator that were not sealed. 3. The facility failed to ensure raw meat was stored separately from raw food. 4. The facility failed to ensure an opened food item in dry storage was dated. These failures could place residents at risk for food-borne illness and cross contamination. Findings Include: Observation of the ice machine on 11/12/2024 at 8:56 am revealed the following: The machine inner guard had black build up along the top of the inner guard. [...]

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 three of six residents (Residents #1, Resident #2, and Resident #3) reviewed for quality of life. The facility failed to answer Resident #1 and Resident #2 call lights in a timely manner. The failure could place residents at risk for complications associated with delayed care such as skin breakdown and dignity issues.

Inspectors wroteBased on, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for ADLs. The facility failed to provide shower/bath ADL care according to resident care plan for June 2024. These failures placed residents at risk of not receiving necessary services to maintain good personal hygiene and decreased self- esteem.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to immediately consult with the resident's physician when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of eight residents reviewed for change in condition. LVN A failed to contact Resident #1's Dr. on 06/08/24, for his drastically decreased BP and he was not transferred to the hospital until 06/09/24. Subsequently, Resident #1 was currently at the hospital diagnosed with septic shock and on a ventilator machine (mechanical life support). An Immediate Jeopardy (IJ) was identified on 06/13/24. An IJ Template was provided to the facility on [DATE] at 10:00 am. [...]

Inspectors wroteBased on observation, record reviews and interviews the facility failed to ensure that based on the comprehensive assessment of a resident, residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1) of eight residents reviewed for quality of care. 1. LVN A failed to provide appropriate treatment and care on 06/08/24 as indicated: a. Did not monitor and check Resident#1's BP after 12:08 pm. b. Did not notify the DON and LVN B, about Resident #1's change in condition and need for continued BP monitoring. c. Did not follow Resident #1's Nephrologist's Doctor order and this facility's Care Plan to ensure the resident did not experience possible fluid overload. 2. [...]

Inspectors wroteBased on record review and interviews the facility failed to provide or obtain laboratory services to meet the needs of its residents for one (Resident #1) of eight residents reviewed for laboratory services. ADON AA failed to follow-up with Resident #1's PA/MD after he received abnormal lab results on 06/03/24. ADON AA failed to get Resident #1's lab reviewed by PA D on 06/05/24. ADON AA faxed lab results for three residents on 06/05/24 but PA D faxed back responses for only two of the residents' labs which did not include Resident #1's labs. This failure could place residents at risk of not getting adequate and timely care and treatment which could cause declines in their health and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for one (Resident #1) of eight residents reviewed for medical records. The facility failed to ensure LVN A and LVN B completely document Resident #1's BP checks and monitoring after Resident #1's BP dropped to 83/44 on 06/08/24 and 06/09/24. The facility failed to ensure Resident #1's standing orders from his nephrologist for a renal diet with fluid restrictions was added to his facility Doctor's orders. These failures could affect all residents and cause errors in care, treatments and diets which could result in a decline in their health and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy for one (Resident #1) of five residents reviewed for privacy. The facility failed to ensure RN A locked the computer, which showed Resident #1's medication and personal information, after he walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others. This failure could cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for one (Resident #2) of five residents reviewed for ADL care. The facility failed to ensure Resident #1 received bath/showers three times a week as per their shower schedule. This failure could place residents at risk of skin breakdown, infection and loss of self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received 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 pressure ulcer treatment. The facility failed to ensure Resident #1 received wound care according to physician orders. This failure could place the resident at risk of worsening wounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to ensure Resident #1 received incontinent care on 03/15/24. This failure could place residents at risk of impaired skin integrity, and decreased feelings of self-worth and dignity. Findings Include: Record review of Resident #1's electronic face sheet, dated 03/15/24, reflected a [AGE] year-old male, who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to participate in the development and implementation of his person-centered plan of care for one (Resident #1) of one resident reviewed for person-centered plans of care. The facility failed to include Resident #1 in his Care Plan Conference. This failure could affect residents and place them at-risk by contributing to inadequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had a right to personal privacy for one of three residents (Resident #2) reviewed for personal privacy in that: Caregiver A failed to ensure the door to Resident #2's room was closed while she assisted in dressing Resident #2. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of three residents (Resident #2) reviewed for accuracy of assessment . The facility failed to ensure Resident #2's care plan was revised to include his tendency to undress himself and leave his room undressed. This failure could place residents at risk of receiving care that did not fully address the resident's needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, which included both the comprehensive and quarterly review assessments for one of three residents (Resident #2) reviewed for accuracy of assessment . The facility failed to ensure Resident #2's care plan was revised to include his tendency to undress himself and leave his room undressed. This failure could place residents at risk of receiving care that did not fully address the resident's needs.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for one (Resident #1) of four residents reviewed for podiatrist services. Resident #1 was not seen by a podiatrist for long, thick, and deformed toenails. This failure placed residents at risk of not receiving foot care consistent with professional standards of practice.

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the physician of a significant change in the resident's health status; or a need to alter treatment significantly for 1 (Resident #1) of 3 residents reviewed for parameters to notify Physician of critical blood pressure levels. 1. The facility failed to notify Resident #'1's physician and administer PRN Clonidine, when Resident #1's systolic blood pressure was over 170, as ordered, on at least four days; on 10/17/23 when the systolic blood pressure was 200, 10/27/23 when the systolic blood pressure was 196, 11/08/23 when the systolic blood pressure was 185, and 11/09/23 when the systolic blood pressure was 181, all when Resident#1's systolic blood pressure was over 170. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for one resident (Resident #1) of three residents reviewed for change in physical, mental, or psychosocial status. The facility failed to give Resident #1 her PRN anti-hypertensive medication as ordered and noted on the care plan. The facility failed monitor and document signs and symptoms of malignant hypertension as noted on the care plan for Resident #1. Resident #1 was sent to the hospital on [DATE] after a change of condition, when Resident #1's initial blood pressure was documented as 214/117, Resident #1 did not eat breakfast, could not swallow, and jaws shifted to the left. Resident #1's hospital admission diagnoses was a hemorrhagic stroke. [...]

Inspectors wroteBased on interview and record review, the facility failed ensure residents were free of any significant medication errors for one (Residents #1) of three residents reviewed for medications. Nurse C failed to give the PRN Clonidine as ordered by the physician for Resident #1 on 10/17/23, 10/27/23, 11/08/23, and 11/09/23, when Resident #'s systolic blood pressure was over 170. Resident #1 was sent to the hospital on [DATE] after a change of condition, when Resident #1's initial blood pressure was documented as 214/117, Resident #1 did not eat breakfast, could not swallow, and jaws shifted to the left. Resident #1's hospital admission diagnoses was a hemorrhagic stroke. Resident #1 passed away at the hospital on [DATE]. An immediate Jeopardy was identified on 12/29/23. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed ensure Maintain an effective pest control program so that the facility is free of pests and rodents for 5 of 5 residents (Resident #22, Resident #34, Resident #79, Resident #92, and Resident #203) reviewed for environment. 1. The facility failed to ensure Resident #22, Resident #34, Resident #79, Resident #92 and Resident #203 had rooms free from house flies. 2. The facility failed to ensure Resident #92's previous room remained free of pests, specifically bed bugs. These failures could place residents at risk of not receiving an home free of pest and comfortable environment to live. Findings Included: Review of the most recent pest control visit dated from 11/12/22 to 10/14/2023, titled Company name Pest Services, Corrective Action Report, revealed Flying Insects. Treated areas of concern. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs for 1 (Resident #253) of 5 residents reviewed for accommodation of needs. The facility failed to ensure Resident #253's call light was placed within her reach. This failure could place dependent residents at risk of injuries and unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan, consistent with resident rights, that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and describe the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #5) of 5 residents reviewed for comprehensive care plans. Residents #5's care plan did not address her use of a hand splint and towel rolls in her hand and at her elbow. This failure could affect the residents in the facility and could result in services and treatments not being provided.

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 2 (Resident #35 and Resident#41) of 8 residents reviewed for ADLs. The facility failed to ensure: 1- Resident #35 was shaved, not having facial hair, and had her fingernails cleaned and trimmed. 2- Resident #41 had his fingernails cleaned and trimmed. This failure could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a 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 (Resident #5) of 5 residents reviewed with limited range of motion. The facility did not ensure Resident #5 was receiving contracture management to treat their contracted hands and elbow. This failure could place residents at risk for decrease in mobility, range of motion and contribute to worsening of contractures.

Inspectors wroteBased on interview, observation, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 (Nurses cart hall C) of 3 carts reviewed for pharmacy services. The facility failed to ensure: 1- LVN D, responsible for nurses cart in hall C, counted controlled drugs every shift change. 2- Medications in unsecure containers were immediately removed from stock. Thes 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: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food safety. 1. The facility failed to ensure the ice machine's filter was free from holes; filter and vent was free from dust; the outside of the machine was free from calcium build up and ice chute guard was clean. 2. The facility failed to ensure food items in the kitchen, refrigerator and dry storage room were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to discard items stored in the dry storage were not properly labeled or past the 'best by', consume by or expiration dates. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 (Resident #5) of 5 residents reviewed for clinical records. The facility failed to ensure staff documented that Resident #5 did not receive her medications on 10/03/23 due to being at the hospital. This failure could affect residents that received medications and place them at risk of inaccurate or incomplete clinical records.

Inspectors wroteBased on observation, interview and record review, the facility failed to obtain information and documentation from hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure 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 (Resident #80) of 5 residents reviewed for hospice services, in that: Facility did not ensure Resident #80's hospice records were a part of their records in the facility. This deficient practice 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 observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Resident #92) of 8 residents reviewed for infection control. The facility failed to ensure: Housekeeper E donned appropriate PPE prior to entering Resident #92's isolated room, and practice proper hand hygiene between change of gloves. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured properly for 1 of 1 nurse wound care/ treatment cart (second-floor nurse station wound care/treatment cart) reviewed for drug storage, as evidenced by: the second floor nurse station nurse wound care/treatment cart was left unlocked and unsupervised. This deficient practice could place residents at risk for harm or theft and place the facility at risk for possible drug diversion.