Giddings Nursing and Rehabilitation

Inspectors wroteBased on observation, 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 3 of 5 residents (Resident #1, Resident #2 and Resident #3) reviewed for quality of life. The facility failed to ensure Resident #1, Resident #2 and Resident #3 received regular showers. This failure could place residents at risk of not receiving services or care, diminished quality of life, infections, rashes and decreased self-esteem.1. Record review of Resident #1's face sheet, dated 06/23/2026, reflected an [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, 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 1 of 5 residents (Resident #2) reviewed for quality of life. The facility failed to ensure Resident #2 received regular showers. This failure could place residents at risk of not receiving services or care, diminished quality of life, infections, rashes and decreased self-esteem. Record review of Resident #2's face sheet, dated 06/24/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for a safe, clean, comfortable, and homelike environment for reviewed for administration in that:1. The facility failed to ensure the Administrator followed the internal drug and alcohol policy.2. The facility failed to ensure the Administrator had his own residence and did not reside in the facility.3. The facility failed to ensure Area ADMIN followed up on reported concerns of the Administrator being drunk, drinking alcohol at the facility, and smoking in areas that were not designated for smoking. These failures placed residents at risk of inadequate supervision, physical, verbal, and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 facility reviewed for freedom from abuse, neglect, and exploitation. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, and distribute food under sanitary conditions in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services.1. The facility failed to label and date all food items located in the kitchen prep area, walk-in refrigerator and freezers observed on 5/20/2026, and 5/21/2026. 2. The facility failed to have closed fitting lids on the trash containers on observed on 5/20/2026, and 5/21/2026. These failures could place residents who receive meals from the kitchen and dine in the facility's dining room at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision to prevent accidents for one of three residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was transported back to the facility utilizing contracted transportation services after an appointment on [DATE]. Resident #1 was transported back to facility by the MTD in the MTD's personal car rather than by the arranged contracted transportation. During the transport, the personal vehicle was involved in a motor vehicle accident. This failure could place residents at risk of mental distress, serious injuries, and hospitalization.

Inspectors wroteBased on observations, interviews, 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, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for two(2) of four(4) kitchen staff (DTA C, [NAME] B) reviewed for food and nutrition services. 1. The facility failed to ensure DTA C met the requirements for food handling by maintaining a valid Food Handler's Certificate. 2. The facility failed to ensure [NAME] B met the requirements for food handling by obtaining a current and valid Food Handler's Certificate before preparing and serving meals out of the facility kitchen. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the residents' environment remained as free of accident hazards as possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one of five residents (Resident #1) reviewed for accidents and hazards. CNA B failed to check the surroundings and notify LVN A when she heard the door alarm on the secured unit on 02/23/2026 at about 2:00 am. Resident #1 eloped from the facility and was found by local PD on a highway about 0.9 miles away from the facility with in the dark on 02/23/26 at 2:25 am. Resident #1 left the facility's secured unit through the door in the lobby area. The noncompliance was identified as PNC. The IJ began on 02/23/26 and ended on 02/25/26. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the resident's right to be free from abuse for one (Resident #5) of 5 residents reviewed for abuse, in that:On 12/25/25 the facility failed to ensure that Resident #5 was not hit multiple times over the head with a plastic trashcan by Resident #4. Resident #5 suffered a laceration, received three staples to his head and required a less than 24-hour hospitalization. This failure could place residents at risk of harm, serious injury and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to have evidence that all alleged violations are thoroughly investigated for 5 of 9 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for abuse and neglect. The facility failed to thoroughly investigate an alleged neglect incident reported by Resident #1 on 12/14/2025 when Resident #1 alleged staff were not performing peri-care appropriately. The facility failed to thoroughly investigate an alleged neglect incident reported by Resident #2's family member on 12/21/2025 when Resident #2 fell and was allegedly left on the floor for over an hour. The facility failed to thoroughly investigate an alleged abuse incident reported by Resident #3 on 12/23/2025 in which Resident #3 stated a pillow was placed over his face by staff around the time of his admission in April 2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for two of eight residents (Resident #4 and Resident #5) in thatThe facility failed to report to [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of property of resident property, establish policies and procedures to investigate any such allegations, and ensure reporting of crimes for 2 of 6 residents (R#1 and R#2).1. The facility failed to ensure R#1 was safe after alleging the ADM harassed, bullied, and picked on him on 12/06/25.2. The facility failed to ensure R#2 was safe after alleging R#1 threatened to choke her with his genitals on 12/06/25.3. The facility failed to ensure an AP was removed upon being notified of abuse and neglect allegations on 12/06/25. 4. The facility failed to report and investigate R#1's and R#2's allegations on 12/06/25. An IJ was identified on 12/15/25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to permit each resident to remain in the facility and not discharge the resident when the resident exercises his or her right to appeal a discharge notice for 1 of 6 residents (R#1). 1. The facility failed to discharge R#1 to a safe environment on [DATE]. R#1 had nowhere to go from [DATE] through [DATE] and was hospitalized on [DATE]. 2. The facility failed to allow R#1 to remain in the facility when he exercised his right to appeal the discharge notice staff served him on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:17 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide notice as soon as practicable before discharge and include the location to which the resident is discharged for 1 of 6 residents (R#1). 1. The facility failed to notify R#1 of his discharge before [DATE].2. The facility failed to include the address where R#1 would be discharged to on the discharge notice he was served on [DATE]. R#1 had nowhere to go from [DATE] through [DATE] and was hospitalized on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:41 p.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 6 residents (R#1). 1. The facility failed to ensure a thorough investigation was completed in regard to the validity of witness statements alleged against R#1 on [DATE]. R#1 was discharged from the facility on [DATE] had nowhere to go from [DATE] through [DATE] and was hospitalized on [DATE].2. The facility failed to take immediate action to ensure the safety of all residents when there is a credible threat to the health and safety of residents alleged against R#1 on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:41 p.m. [...]

Inspectors wroteBased on interview and record review the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including the category of work for each person on direct care, including, but not limited to, whether the individual was a registered, nurse, licensed practical nurse, licensed vocational nurse, certified nursing assistant, therapist, or other type of medical personnel as specified by CMS for one of one facility reviewed for administration. The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for October 1, 2024, to December 31, 2024. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute food under sanitary conditions in accordance with professional standards for food service safety for 1 of 1 kitchen.1. The facility failed to label and date all food items located in the walk-in refrigerator, freezers and in the dry food pantry area on 7/15/2025, and 7/16/2025. 2. The facility failed to clean and sanitize its food storage areas, to include the shelves and 1freezer in storage room. on 7/15/2025, and 7/16/2025.3. The facility failed to clean and sanitize its dining area on 7/15/2025, 7/16/2025, and 7/17/2025. These failures could place residents who receive meals from the kitchen and dine in the facility's dining room at risk for foodborne illnesses. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 7 (Resident #5, Resident #8, Resident #22, Resident #27, Resident #15, Resident #39, and Resident #42 of 11 residents reviewed for infection control practices, in that: The facility failed to:1. Ensure CNA B and Medication Aide A practiced proper hand hygiene while serving and assisting residents #22, #27, and #42 during the lunch meal on [DATE].2. Ensure CNA C changed dirty gloves when handling clean items while providing peri care to Resident #8.3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for one of five residents (Resident #14) reviewed for dignity. The facility failed to speak to Resident #14 in a way that promoted her dignity and self-worth. This failure could place residents at risk of a decline in their sense of dignity, level of satisfaction with life, and feeling of self-worth.

Inspectors wroteBased on observation, 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 two of eight residents (Resident# 12 and Resident #16) reviewed for ADL care. The facility failed to ensure Resident #12, and Resident # 16's nails were cleaned, and did not have rough edges. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on interview, observation and record review, the facility failed, to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of five residents ( Resident # 15 and Resident #25) reviewed for activities. The facility failed to provide Resident #15 and Resident #25 in room activities on the dates of 07/01/2025 thru 7/17/2025. This failure could place residents at risk for boredom, depression, and diminished quality of life. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage properly in 1 of 1 kitchen. On 07/15/2025 at 9:30 AM, 1 of 2 facility garbage containers were observed with no lids attached or on them and they had waste inside. This failure has the potential to affect residents in the facility, staff, and visitors by placing them at risk of infection for exposure to germs and diseases carried by pests and rodents. In an interview with Dietary Supervisor on 07/16/2025 at 3:15 PM, Dietary Supervisor stated that trash cans should always have lids and should remain closed when not in use. Dietary Supervisor stated not keeping the lids closed could lead to cross contamination, placing residents at risk of illness. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for one of one kitchen reviewed for effective pest control. The facility had presence of mouse droppings on a shelf in the food storage room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Observation on 07/15/2025 at 9:22 AM, in the facility's kitchen food storage room revealed several mouse droppings on the bottom shelf. In an interview with Dietary Supervisor on 07/16/2025 at 3:15 PM, she stated it looked like mouse droppings to her as well on the shelf. Dietary Supervisor stated the maintenance department was responsible for pest control. She stated the shelf would be cleaned that day. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #1) of 4 residents review for catheter care. The facility failed to change Resident #1's foley catheter (a medical device used to drain urine from the bladder.) as ordered monthly on 04/09/2025 and 5/9/2025. Resident #1 was sent to the local ER on [DATE] due to fever and lethargy and was diagnosed with possible sepsis (is a life-threatening condition that occurs when the body has extreme response to infection). This failure resulted in an identification of an Immediate Jeopardy (IJ) on 05/19/2025 at 4:19 pm and an IJ template was given. [...]

Inspectors wroteBased on interview, 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 (Resident #1) of 4 residents review for pharmacy services. The facility failed to carry out Resident #1's orders from the hospital for insulin to control his blood glucose. Resident #1 was sent to the local ER on [DATE] due to fever and lethargy and was diagnosed with Diabetes Ketone Acidosis (DKA-Diabetes Ketone Acidosis is serious and can be life threatening. DKA is when your body doesn't have enough insulin to allow blood sugar into your cells for use as energy (with a blood serum level of 478. Normal blood serum glucose levels: Fasting blood glucose 70 to 99 mg/dL. Random blood glucose: generally, it should be 125 mg/dL.) . [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes 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 (Resident #1) out of four residents reviewed for the development of the comprehensive care plans. The facility failed to ensure Resident #1 had a comprehensive person-centered care plan completed to reflect Resident #1's care needs for Catheter, Diabetes, Oxygen therapy, medications (antibiotics , anti-hypertensive, anticoagulant), and Cognition. This deficient practice places the resident at risk for not receiving the necessary and appropriate care.

Inspectors wroteBased on interviews, 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 infection for 2 of 5 residents (Residents #1 and #2) reviewed for infection control. The facility failed to ensure Resident #1 was placed on Isolation after she tested COVID-19 (Coronavirus 2019) positive in the hospital on [DATE]. The facility failed to have signage on Resident #1's door that reflected PPE was required for infection control. The facility failed to removed Resident #2 from a COVID-19 positive room even though she tested negative for COVID. These failures could place residents at risk for infection, or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #5) of 7 residents reviewed for resident rights. The facility failed to honor Resident #5's request of being assisted out of bed on 02/09/25. This failure could place resident at risk for depression, diminished quality of life and isolation.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical and psychosocial status for one (Resident #4) of seven residents reviewed for changes in condition. 1. The facility failed to notify Resident #4's RP of Resident #4 being hit by a peer on 2/3/25. 2. The facility failed to notify Resident #4's RP of a visit to the ER after Resident #4 had a fall on 2/7/25 with an onset of increased confusion. These failures could put residents at risk of not having their care needs and health changes communicated and addressed with their responsible party.

Inspectors wroteBased on interview and record review, the facility failed to, in response to allegations of abuse, neglect or mistreatment, have evidence that all alleged violations were thoroughly investigated for two (Residents #4 and #7) of seven residents reviewed for abuse and neglect. The facility failed to investigate an allegation of abuse when Resident #7 hit Resident #4 on her face on 2/3/25. This failure placed residents at risk of further abuse, trauma, and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 7 residents (Residents #5 and #7) reviewed for care plans. 1. The facility failed to ensure the comprehensive care plan for Resident #5 included the need for a mechanical lift transfer with the assistance of 2 staff. 2. The facility failed to ensure Resident #7's comprehensive care plan included aggressive behaviors. These failures could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for one (secure hall) of three halls reviewed for physical environment. The facility failed to ensure an exit door on the secured unit contained an alarm to alert staff if a resident exited the door. This deficient practice could place residents at risk of injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #1) of 4 residents reviewed for resident rights. The facility failed to honor Resident #1's request of being assisted out of bed between 8:30 and 9:00 AM on 09/12/2024. This failure could place resident at risk for depression, diminished quality of life and isolation.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure the comprehensive care plans for Resident #1 included ADLs, behaviors, and diagnosis of mental illness on 07/25/2024. This failure could affect residents by placing them at risk of not receiving appropriate physical and psychosocial care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident# 25) reviewed for elopement and failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 1 shower rooms reviewed for quality of care. A) The facility failed to ensure Resident #25 was monitored for wandering and elopement. Resident #25 eloped from the facility on 05/14/2024 without facility knowledge and was found at the convenience store 0.4 miles away. An immediate Jeopardy (IJ) situation was identified on 05/29/2024 at 1:22 PM. While the IJ was removed on 05/31/2024 at 1:00 PM, the facility remained out of compliance because of the facility's need to evaluate the effectiveness of its corrective systems. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 4 quarters reviewed for payroll data information (Quarter 1 2024). The facility failed to submit PBJ staffing information to CMS for the 1st quarter ([DATE] to March 30) of fiscal year 2024. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment for 5 of 15 of Residents (Residents #27, #5, #13, #1 and #19), 1 of 1 outside facility grounds, and 1 of 1 shower rooms reviewed for homelike environment. A) The facility failed to ensure Resident #27's bathroom soap dispenser was attached to the wall on 05/28/2024 at 09:38 AM. B) The facility failed to ensure Resident # 5's remote control cord for her bed was intact and functional on 05/28/2024 at 09:40 AM. C) The facility failed to ensure Resident #13's window blinds were intact and not missing slats on 05/28/2024 at 09:40 AM. D) The facility failed to ensure Resident #1's window blinds were attached to the top of her window; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents goals and preferences for 4 of 4 residents (Residents #88, #22, #19 and #24) reviewed for respiratory care. A. The facility failed to ensure Resident #80's CPAP mask was covered with a dated plastic bag on 05/28/2024 at 9:52 AM B. The facility failed to ensure Resident #22's nebulizer mask was covered with a dated plastic bag on 05/29/2024 at 2:33 PM. C. The facility failed to ensure Resident #19's oxygen tubing was dated on 05/28/2024 at 11:02 AM and failed to ensure her nasal cannula was covered with a dated plastic bag when not in use. D. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all expired drugs and biologicals were removed and destroyed for 1 of 1 medication storage rooms reviewed for medications and failed to ensure 1 of 1 medication storage room refrigerators was free of contaminants. The facility failed to remove 7 bottles of expired medication from the medication storage room and 1 container of expired protective skin applicators when it was observed on 05/28/2024 at 3:45 PM. The facility failed to ensure the medication room refrigerator was free of contaminants including staff food and drinks when it was observed on on 05/28/2024 at 3:45 PM. This failure could place all residents at an increased risk of receiving expired and/or contaminated medications/supplements resulting in adverse health consequences.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 1 dining rooms and 1 of 1 shower room reviewed for environment. The facility failed to ensure the dining room was free of flies during the resident meal service on 05/28/2024 at 12:15 PM. The facility failed to ensure the shower room was free of roaches and water bugs on 05/29/2024 at 1:15 PM. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live.

Inspectors wroteBased on interview, and record review the facility failed to ensure that all alleged violations involving neglect were reported immediately to the state survey agency, for 1 of 1 resident (Resident# 25) reviewed for elopement. The facility did not report to the state survey agency when Resident #25 eloped from the facility on 05/14/2024 without facility knowledge and was found at the convenience store 0.4 miles away. This failure places residents at risk for elopement, accidents, and heat exhaustion due to lake of supervision.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents had orders and followed physician's orders for the resident's immediate care for 1 of 15 Residents (Resident #80) reviewed for admission orders. The facility failed to provide physician's orders for fingerstick blood sugar checks for Resident #80 who was admitted to the facility on [DATE]. The facility failed to check Resident #80's blood pressure per Physician's orders. This failure could place the resident at risk of not receiving necessary care and services upon admission that could result in a deterioration of her condition.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 1 of 15 residents (Resident #80) reviewed for baseline care plans. The facility failed to ensure Resident #80's baseline care plan dated 05/28/2024 included instructions to address her admission diagnosis, Type 2 Diabetes (long term condition in which the body has trouble controlling blood sugar and using it for energy) and physician orders within 48 hours of admission. Resident #80 was admitted to the facility on [DATE]. This failure could place residents at risk of receiving inadequate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 out of 8 residents reviewed for comfortable and safe temperature levels. The facility failed to ensure the dining area was within 71-81 degrees Fahrenheit . This failure could place residents susceptible to loss of body heat and an uncomfortable setting.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains free of accidents and hazards for one (1) (Resident #1) of four (4) residents reviewed for accidents and hazards. The facility failed to properly supervise Resident #1 and as a result she had a cigarette lighter stored in her room. This deficient practice placed residents at risk for accidents resulting in injuries or hospitalization related to burns or fire.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for two (Nurse medication cart and Nurse treatment cart) of four (4) medication carts reviewed for medication storage. The facility failed to prevent the Nurse's medication cart and Nurse's treatment cart from being unattended and unlocked. This failure could place residents, unauthorized staff and visitors access to medications that could cause physical harm and decreased quality of life .

Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan after each assessment, including comprehensive and quarterly review assessments, for 2 of 4 residents (Resident #1 and #2) reviewed for care plan timing, in that: 1. Resident #1's quarterly MDS assessment was completed on 08/08/23 and her most recent comprehensive person-centered care plan was revised and completed on 01/06/2023. 2. Resident #2's quarterly MDS assessment was completed on 07/20/23 and his most recent comprehensive person-centered care plan was revised and completed on 02/03/2023. This deficient practice could place residents at risk of not having their current preferences, goals, and needs met.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for four of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 03/05/23, 03/12/23, 03/19/23, and 03/25/23. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for two (Resident #25 and Resident #2) of 12 residents reviewed for quality of care. 1. The DON failed to ensure Resident #25's GI consult was scheduled in a timely manner. 2. Resident #2 was not wearing compression bandages as ordered on 3/29/2023 and 03/30/23 and did not receive monitoring for edema as ordered. These failures placed residents at risk of delayed care and services in accordance with professional standards of practice.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases for two of four residents (Residents #11 and #12 and 1 of 1 LVN (LVN A) reviewed for fingerstick blood sugar checks. LVN A failed to sanitize the common glucometer, which is used during blood testing between resident blood sugar checks for Resident #11 and #12. This failure could place residents at risk of exposure to blood-borne diseases. Findings Included: Observation on 03/28/2023 at 10:59 AM, revealed LVN B preparing to perform a finger stick blook sugar (FSBS) test on Resident #12. LVN B removed the glucometer from the cart and placed the glucometer on the cart without cleaning the cart. [...]