Gracy Woods Nursing Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to be treated with respect and dignity, including the right to retain and use personal possessions, including furnishings, and clothing, as space permits, unless to do so would infringe upon the rights or health and safety of other residents for 3 of 12 residents (Residents #8, 19 and 25) reviewed for dignity and use of personal possessions. The facility failed to ensure NA K treated Resident #19 and Resident #8 with dignity when he tried to provide Resident #19 redirection and walked into Resident #8's room while speaking into a Bluetooth earpiece. The facility failed not to clutter Reisdent#25's space in her room with facility owned oxygen concentrator, oxygen cylinder and laundry basket of her roommate. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who is unable to carry out activities of daily living, receives the necessary services to maintain grooming and personal care for 3 of 8 residents (Resident #45 and Resident #88 and Resident #67) reviewed for ADL care. The facility failed to provide nail care to Resident #45 and Resident #88 and Resident #67, leaving the nails on the fingers and toes , long, and discolored. This failure could place residents at risk of social embarrassment, isolation, infection, injury, pain, deterioration of health and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 1 resident (Resident #38) reviewed for privacy. The facility failed to ensure CNA D and CNA E provided privacy by drawing the privacy curtain during incontinent care for Resident #38. This failure could place residents at risk of feeling embarrassed, diminishing the residents' quality of life and not having residents' rights acknowledged. Findings Included: Record review of Resident #38's undated face sheet reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #38) of 1 resident reviewed for incontinent care with foley catheter. The facility failed to ensure Resident #38's catheters' drainage bag was positioned lower than Resident's urinary bladder to prevent urine from flowing back to urinary bladder. This failure could place residents at risk of UTI and other serious infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to adequately equip to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area from each resident's bedside for 2 of 32 residents (Residents #53 and 84) reviewed for call system. The facility failed to ensure Residents #53 and 84 had functioning nurse call buttons on 06/02/2026, 06/03/2026, and 06/04/2026. This failure placed residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility for 1 of 4 required postings (survey results) reviewed. The facility failed to ensure the results of the recertification survey dated 12/31/2026 were present in the survey inspection results binder on 06/02/2026 and 06/03/2026. This facility placed residents and their responsible parties at risk of not being able to inspect survey results.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 4 shower rooms (halls 200, 300, and 500) and 1 of 1 medication room reviewed for environment. The facility failed to ensure the shower rooms for halls 200, 300, and 500 were clean, functional, and in good repair on 05/13/2026 and 05/14/2026. These failures could place residents at risk of infection, injury, and diminished quality of life. Record review of work orders dated 04/13/2026 to 05/13/2026 reflected no work order related to the shower rooms or the medication room sink and cabinet. All work orders on the list were completed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 2 medication carts (Cart A) reviewed for pharmacy services. 1. The facility failed to ensure medications in the hall 400 medication cart (Cart A) were stored in a clean environment. 2. The facility failed to follow its pharmacy services policy when it allowed storage of a dose of Resident #1's Tramadol taped into a compartment with a broken seal. These failures could place resident's medications at risk of prompt identification of loss, and potential diversion of controlled medications. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 1 medication room reviewed for environment. The facility failed to ensure the medication storage room sink and the under-sink cabinet was in good repair on 05/13/2026 and 05/14/2026. These failures could place residents at risk of not receiving the full benefit of their pharmaceutical regimen and infection. Record review of work orders dated 04/13/2026 to 05/13/2026 reflected no work order related to the shower rooms or the medication room sink and cabinet. All work orders on the list were completed. [...]

Inspectors wroteBased on interviews, 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 promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality and failed to protect and promote the rights of the residents for 1 of 5 (Resident #1) residents observed for dignity. 1. The facility failed to ensure Resident #1 was clean while in the dining room being assisted with feeding. Resident #1 was in the dining room being fed with fecal matter on both of his hands. This failure could place residents at risk of experiencing humiliation, degradation, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control/sanitary environment. The facility failed to ensure staff performed hand hygiene for Resident #1 and fecal matter was removed from his hands prior to being fed in the dining room. This failure could place residents at risk for developing communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to date food and beverages found within the facility's freezer and refrigerator on 12/29/2025The facility failed to date and properly seal food products in facility freezer and refrigerator on 12/29/2025. These failures could place the residents who ate food from the kitchen at risk of cross contamination, loss of nutritional value, weight loss, and foodborne illness.

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure evidence reflects the facility did not complete a discharge summary to include a recapitulation of the resident's stay and a final summary of the resident's status at the time of discharge as resident was discharged to the hospital for a change in condition and the family chose to not readmit to the facility for 1 (Resident #94) of 4 residents reviewed for safe transfer or discharge. The facility failed to record the reasons for the transfer/discharge in Resident # 94's medical record when discharged on 11/30/2025. This failure could place residents at risk of being discharged without alternative placement, discharge options, their rights to appeal and access to advocacy services.

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement an accurate comprehensive person-centered care plan that met the residents' medical needs and treatment plan for 1(Resident # 38) of 6 residents reviewed for comprehensive care plans. The facility failed to provide interventions / approaches consistent with facility policy of being a non-smoking facility for Resident # 38 vape use listed as a problem on her care plan. This failure could affect residents by placing them at risk of not receiving appropriate interventions and care to meet their current needs.

Inspectors wroteBased on interview and record review the facility failed to ensure professional staff were licensed certified or registered in accordance with applicable state laws for 13 Nurse Aides of 13 nurse aides reviewed for assessments. The facility failed to ensure NAs A, B, C, D, E, F, G, H, I, J, K ,L ,M, Nurse Aide Curriculum skill performance checklists were checked off. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being.

Inspectors wroteBased on interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan to meet the preferences and goals of each resident and address the resident's medical, physical, mental and psychosocial needs for one (Resident #1) of three residents reviewed for care plan. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents, hazards, and supervision. The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found 26 hours after he eloped. The facility did not have a plan in place for monitoring the windows to ensure resident supervision/monitoring was in place to prevent Resident #1's elopement. On 09/12/2025 at 5:05 p.m., an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on observation, interviews, and record reviews; 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 sanitation. 1. The facility failed to dispose of open stored perishable food products. 2. The facility failed to properly label and date food products in the walk-in refrigerator and walk in freezer. 3. The facility failed to ensure Dietary Manager wore a facial hair restraint while performing duties throughout the kitchen. These failures could place residents who were served from the kitchen at risk for consuming contaminated food and developing foodborne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodations for 2of 6 residents (Resident # 73 and Resident #47) reviewed for resident rights. The facility failed to ensure:*Resident #73 could communicate his needs and preferences. *Resident #47 had access to call light button. These failures could place residents at risk of isolation, not receiving needed care or nursing interventions to meet the resident's needs.

Inspectors wroteBased on interview and record review, the facility failed to establish and maintain a homelike environment for 2 or 3 residents (Resident #87 and Resident #14) observed for environmental conditions. The facility failed to ensure Resident #87's and Resident #14's bedroom walls were upkept and homelike. This failure could cause residents psychological distress or feel uncomfortable. Based on interview and record review, the facility failed to establish and maintain a homelike environment for 2 or 3 residents (Resident #87 and Resident #14) observed for environmental conditions. The facility failed to ensure Resident #87's and Resident #14's bedroom walls were upkept and homelike. This failure could cause residents psychological distress or feel uncomfortable. [...]

Inspectors wroteBased on observation, 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 3 of 5 residents (Resident #44 and Resident #41 and #103 of 4 medication carts MC A reviewed for pharmaceutical services. 1. The facility failed to document controlled medications from the medication cart on the narcotic count sheets for Resident #44, Resident #41, and Resident #103. 2. The facility failed to remove a discontinued bottle of controlled medication from the medication cart for Resident #103. This failure could place residents at risk of medication errors and drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #2, Resident #63, and Resident #33) and 2 of 5 staff (LVN C and CNA A) reviewed for infection control. 1. The facility failed to ensure CNA A was conducting hand hygiene between each resident when passing lunch trays on hall 500. 2. The facility failed to ensure LVN C was sanitizing surfaces before and after when providing wound care for Resident #2, Resident #63, and Resident #33. These failures could place residents at risk of transmission of disease and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all routine and emergency drugs and biologicals for 1 of 4 residents (Resident #1) reviewed for pharmacy services.1. The facility failed to ensure Resident #1's ciprofloxacin-dexamethasone (antibiotic ear drops) was acquired and administered according to physician's orders. These failures could place residents at risk for not receiving therapeutic dosages of their medications as ordered by the physician and a potential for decreased health status and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to include effective communications as mandatory training for 16 of 16 employees (MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW) reviewed for training requirements. The facility failed to provided MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ AND SW with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review, the facility failed to include training on the QAPI program to outline and inform staff of the elements and goals of the facility QAPI program for 16 of 16 employees (MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW) reviewed for training requirements. The facility failed to provide MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ AND SW on the QAPI program as mandatory training. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review the facility failed to communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for 16 of 16 employees (MDS, CNA S, CNA T, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW) reviewed for training requirements. The facility failed to provide MDS, CNA S, CNA T, CNA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ AND SW on the compliance and ethics program's standards, policies and procedures through a training program or other practical manner as required. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 5 of 24 resident rooms for Residents #69, #74, #31, #12, #15 whose rooms were observed for housekeeping and maintenance services. 1. Resident #69's room did not have a pull string for the overhead light, the wall paper on the wall behind the head of the bed was peeling off, the cover to a drawer on the right bottom closet was missing, and the privacy curtain was torn from the top and the torn portion was used to tie the bottom of the curtain so it would not drag on the floor. 2. The facility failed to provide a functional accessible bathroom and a functioning light switch with a plate cover in Resident #74's room. 3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 5 of 21 residents (Resident #13, #31, #70, #69, and #74) reviewed for care plans: 1. The facility failed to ensure Residents #13's Care Plan reflected they refused staff assitance with their personal refrigerated items. 2. The facility failed to ensure Residents #31's Care Plan reflected they refused staff to assist with their personal refrigerated items. 3. The facility failed to ensure Residents #70's Care Plan reflected they refused staff to assist with their personal refrigerated items. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 8 medication carts and 2 of 21 Residents (Resident #72 and #84) reviewed for labeling and medication storage: 1. The facility failed to ensure the medication cart used on the 200-unit had pharmacy labels on 7 out of 11 insulin pens in the cart, medications were not left on the mediation cart counter, and the medication cart was locked. 2. The facility failed to ensure the medication cart used on the 400-unit was locked and medications were not left on the medication cart counter. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 6 (DA K, DA L, DA M, DA N, DW P, and DA O ) of 10 dietary staff reviewed for qualified dietary staff, in that: The facility failed to ensure the DA K, DA L, DA M, DA N, DW P, and DA O had their Texas Food Handler Certificate. This failure could place residents who ate food from the facility's kitchen at risk of not having their nutritional needs met and place them at risk for food born illnesses.

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: 1. The facility failed to have hand soap at the handwashing station in the kitchen. 2. The facility failed to keep dish racks and juice lines off the floor. 3. The facility failed to not store a basket of milk cartons on the walk-in cooler floor. 4. The facility failed to date an open package of turkey and 2 open bags shredded cheese. 5. The facility failed to date a container of onions, discard a rotten potato, close a bag of grits, and to store an open bottle of sauce in the refrigerator. 6. The facility failed to cover Resident #36's lunch tray when placed on the hallway cart. 7. The facility failed to ensure the ice machine was clean and there was a cleaning log. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 (Residents #70 and #31) of 3 residents reviewed, in that: 1. Resident #70's personal refrigerator was observed to have spoiled food and no temperature log. 2. Resident #31's personal refrigerator was observed to have expired food and an incomplete temperature log. This deficient practice could place residents at risk of foodborne illness due to consuming foods which might be spoiled.

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 infection for 5 of 21 residents (Resident #89, Resident #67, Resident #40, Resident #66, and Resident #74) reviewed for infection control: 1. The facility failed to ensure LVN A practiced proper hand hygiene when administering medications to Resident #89, Resident #67, and Resident #40. 2. The facility failed to ensure LVN J wore a gown during peg tube medication administration for Resident #66 who had orders for EBP and did not contaminate her gloves. 3. The facility failed to ensure Resident #74's indwelling urinary catheter bag was not on the floor. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. The facility failed to ensure 1 of 2 washing machines and 1 of 2 dryers were operable. These failures could place residents at risk of needs not being met due to equipment not being operable.

Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 09 of 16 employees (CNA W, CNA Y, DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW ) reviewed for training, in that: The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA W, CNA Y, DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 7 of 16 staff (DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to DS, ACT D, LVN FF, LVN GG, RN HH, LVN JJ, and SW. This failure could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory behavioral health training for 15 of 16 employees (MDS, CNA S, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to MDS, CNA S, MA U, CNA V, CNA W, CNA Y, CNA Z, DS, ACT D, LVN FF, LVN GG, RN HH, RN II, LVN JJ and SW. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 8 residents (Resident #36) reviewed for grievances. The facility failed to fully investigate and address Resident #36's grievance report of missing personal property, including two computers, a wallet, DVDs, and food items, and did not assist Resident #36 in replacing his identification and bank card. This failure could place residents at risk for not having their grievances resolved.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from Misappropriation of property for one (Resident #36) of 8 residents reviewed for misappropriation of property. The facility failed to ensure Resident #36 was free from misappropriation of property when he was forced to leave his room and belongings after a bed bug infestation and when he returned his wallet, DVDs, snacks, and two laptops were missing. This failure could place residents at risk of Exploitation/Misappropriation of Property and financial distress.

Inspectors wroteBased on interviews 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, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 1 (Resident #36) of 8 residents reviewed for abuse. The facility failed to report to the state agency when Resident #36 alleged his wallet, DVDs, snacks, and two laptops were missing. This failure could place residents at risk of Exploitation/Misappropriation of Property and financial distress.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to ensure that the resident's environment remained free of accidents and hazards as was possible and each resident received adequate supervision to prevent accidents for 2 (Resident #47, and Resident #70) of 21 residents reviewed for accidents. 1. The facility failed to ensure Resident #47 did not have an insulin needle on her bedside table. 2. The facility failed to ensure Resident #70 did not have a power strip in his room and a fan plugged into it. This failure could place the resident at risk of hazards and/or accidents.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #21) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #21. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, 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 2 of 8 residents (Residents #69 and #66) reviewed for medications and pharmacy services: 1. MA D prepared Resident #69's medications and allowed LVN A to administer them to the resident. 2. The facility failed to ensure LVN J administered all of Resident #66's arginine-based powder mixture (designed to support the unique nutritional needs of people with chronic wounds. It delivers 4.5 grams of L-arginine and Vitamins C and E for wound management.) via his PEG tube (is a surgery to place a feeding tube. [...]

Inspectors wroteBased on observation, and interview the facility failed to dispose of garbage and refuse properly for 1 of 2 Dumpsters (Dumpster #1) reviewed for disposal of garbage. The facility failed to ensure Dumpster #1 was closed and trash was not on the ground outside the dumpster and around the facility grounds. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records on each resident that were complete and accurately documented for 2 of 21 residents (Residents #69 and Resident #74) reviewed for medical records. 1. The facility failed to ensure Resident #69's physician's orders were updated to include the resident no longer received a puree diet, thickened liquids, and crushed medications. 2. The facility failed to ensure Resident #74's physician's orders were updated to include the resident was a DNR status. These deficient practices could place residents at risk of improper care due to inaccurate medical records.

Inspectors wroteBased on observations, record reviews, and interviews the facility failed to ensure resident rooms were equipped to assure full visual privacy for each resident for 1 (Resident #66) of 21 rooms reviewed for full visual privacy. The facility failed to provide Resident #66 with a privacy curtain. This failure could cause a decrease in feelings of self-worth by being exposed during cares.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 2 of 6 residents (Residents #1 and Resident #2) reviewed for infection control, as indicated by: CNA A, CNA B and CNA C failed to change dirty gloves while handling clean items while providing peri care to Resident #1 and, Resident # 2. This failure could place the residents at risk of transmission of diseases and infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart and ensure infection control measures during implementation of care, handling, cleaning, storage and disposal of equipment, supplies, biohazardous waste and including infection control practices for mechanical ventilation/tracheostomy care including the use of humidifiers were followed by staff for 1 (Residents #1) of 5 residents reviewed for respiratory care, The facility failed to ensure Resident #1's nasal cannulas and tubing were properly stored when not in use. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that pain management was provided to a resident who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for pain, in that: The facility failed to: Provide pain medication ordered for resident with a diagnosis of malignant cancer who suffered from chronic pain. An Immediate Jeopardy (IJ) was identified on 04/23/2024. The IJ template was provided to the facility on [DATE] at 5:57 PM. [...]

Inspectors wroteBased on observation, 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 of 4 residents reviewed (Resident #1) for pharmacy services. The facility failed to: Provide pain medication ordered, for three consecutive months for different time frames, for resident with a diagnosis of malignant cancer who suffered from chronic pain. An Immediate Jeopardy (IJ) was identified on 04/23/2024. The IJ template was provided to the facility on [DATE] at 5:57 PM. [...]

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 that are identified in the comprehensive assessment for 1 of 4 residents reviewed (Resident #2) reviewed for care plan, in that: The care plan for Residents #2 failed to address any of the resident's need, because Resident #2 did not have a care plan. These failures could affect the resident by placing him at risk for not receiving care and services to meet his needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

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 2 of 16 (Resident #1, and Resident #2) residents in 1 of 1 dining room. The facility failed to promote Resident #1 and 2's dignity while dining when staff did not serve the residents their lunch tray at the same time as other residents at the same table. This failure could affect all residents who were eat in the dining room, by contributing to poor self-esteem, and unmet needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rights for personal privacy for two of seven (Resident # 3, and Resident # 4) residents observed for resident rights. CNA B and CNA C did not provide privacy to Resident #4 when providing care. The facility failed to provide privacy to Resident #3 while she was lying in bed with no clothing on from the waist down. The deficient practice could affect all residents in the facility by placing them at risk for loss of dignity and privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had the right to be free from abuse for 2 residents (Resident #1 and Resident #2) of 7 residents reviewed for abuse/neglect. CNA A called Resident #1 dumb and asked why he can't change himself when he asked for assistance on Thursday, 3/7/24 at approximately 8:30 pm. Resident #1 stated CNA A's words made him feel embarrassed and angry. Resident #3 entered the room of Resident #2 on Saturday 3-02-24, and hit Resident #2 on the foot 4 times. This failure could place residents at risk of fear and physical/psychosocial injury.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from neglect for 3 (Residents # 71, 85 and 87) of 5 residents reviewed for neglect. The facility failed to ensure Resident #s 71, 85 and 87 were ordered nutritional supplements to promote wound healing based on risk factors based on standard of care. The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. Resident #71 died in the local hospital on [DATE] due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) and infected wounds. Resident #85 was transferred to the local hospital on [DATE] and diagnosed with sepsis. [...]

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 3 (Residents # 71, 85 and 87) of 5 residents reviewed for pressure ulcer care. The facility failed to ensure Resident #s 71, 85 and 87 were ordered nutritional supplements to promote wound healing based on risk factors based on standard of care. The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance for 1 of 8 residents (Resident #71) reviewed for nutrition. The facility failed to ensure dietitian interventions of increased tube feedings and speech therapy were implemented when Resident #71 had a 10% weight loss in November 2023, leading to an overall weight loss of 32% from July 2023 to January 2024. Resident #71 also developed pressure wounds on her foot and hip that worsened, and she died on [DATE]. The noncompliance was identified as PNC. The IJ began on 11/16/23 and ended on 01/17/24. The facility had corrected the noncompliance before the survey began. The failure placed residents at risk of unplanned weight loss, malnutrition, worsening of wounds, and death.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure nursing staff had the appropriate competencies and skills sets to provide nursing and related services in accordance with professional standards of practice for 1 (Resident # 87) of 2 residents observed for wound care by 1 (Wound care nurse A) of 1 wound care nurse reviewed for competency, in that: 1) TLVN S did not perform hand hygiene and change her gloves while performing wound care on Resident #87 on 01/19/2024. TLVN S also performed wound care on Resident #87's two wounds at the same time. The facility failed to ensure TLVN S, TLVN T and RN I had skills and competencies completed to perform wound care on 01/19/2024. An IJ was identified on 01/19/2024 at 5:10 pm. The IJ template was provided to the facility on [DATE] at 5:03 pm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 24 residents (Resident #71, #85, and #87 and Resident #73) reviewed for infection control, in that: 1 The facility failed to prevent Resident #71's, 85's and 87's wounds from getting infected. Resident #71 died in the local hospital [DATE] due to sepsis (a serious condition resulting from the presence of harmful microorganism in the blood or other tissues and the body's response to their presence, potentially leading to the malfunctioning of various organs, shock, and death.) and infected wounds. Resident #85 was transferred to the local hospital on [DATE] and diagnosed with sepsis. Resident #87 was diagnosed with a wound infection on [DATE]. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident who requires dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for three (Resident #1, Resident #2, and Resident #3) of four residents reviewed for dialysis, in that: The facility failed to ensure current active physician's orders for the type or frequency of dialysis treatments were in place for Resident #1, Resident #2, and Resident #3 and that physician's orders were in place for monitoring the dialysis access site for Resident #1. These failures could place residents on dialysis at risk of severe blood loss, infection control complications, and hospitalization.