Greenview Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASARR) Level I residents with a mental illness was completed correctly and were provided with a PASARR Level II assessment for one (Resident #1) of four residents reviewed for resident assessments. The facility failed to ensure the PASARR Level 1 screening for Resident #1 was completed accurately and timely. This failure could place residents at risk of not receiving the appropriate care and services to meet their needs.

Inspectors wroteBased on interview, and record review, the facility failed to implement a comprehensive care plan that describes the services to be furnished to attain or maintain the highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents(Resident #1) reviewed for care plans. The facility failed to revise Resident #1's care plan to reflect behavior and intervention when he urinated on the floor in the commons area due to dementia on 07-07-2026. This deficient practice placed residents at risk of not having their individualized needs met and communicated to providers that could result in a decline in physical well-being.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had the right to retain and use personal possessions, including clothing, as space permits, unless to do so would infringe upon the rights of others for 3 of 10 residents (Resident #11, Resident #31, and Resident #106) reviewed for respect and dignity. The facility failed, for an undetermined period, to return residents' clothing to them after they had been laundered causing Residents #11, #31, and #106 to be mad. This failure could place residents at risk of their clothing not being returned, lost, stolen, and not having adequate clothing options. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 3 of 6 residents (Residents #28, #72, and #87) reviewed for resident rights. The facility failed to ensure Resident's #87's and Resident #72's call light was within reach on 05/27/26. The facility failed to ensure Resident's #28's and Resident #72's call light was within reach on 05/28/26. This failure could place residents at risk of needs not being met.

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 one of one kitchen reviewed for sanitation. The facility failed to date all items after they were opened. The facility failed to properly label and date all items in the freezer. The facility failed to maintain clean cooking equipment. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pests. The facility failed to ensure the kitchen was free of flies on 5/27/2026, 5/28/2026 and 5/29/2026. These failures could place residents at risk for insect borne illness, infection and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (room [ROOM NUMBER]) of six resident rooms reviewed for a clean and homelike environment. The facility failed to ensure room [ROOM NUMBER] did not have spattered and smeared yellowish-brown, chunky substance appearing consistent with vomit on the floor beneath and beside the bed and the room was free of a bitter foul odor. The failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation and interview, the facility failed to provide IV maintenance in accordance with standards of practice for one of one residents (Resident #22) reviewed for IV maintenance care. On 5/29/2026, Nurse G failed to adhere to sterile technique during maintenance of IV therapy port for Resident #22 This failure could cause residents infection, pain and decreased quality of life.

Inspectors wroteBased on observation, interview, and records review, the facility failed to ensure proper labeling, storage and disposal of the drugs and biologicals in a safe manner for two of six medication carts (Medication Cart #1 and Medication Cart #2) inspected on 5/28/2026. The facility failed to dispose of:- One bottle of concentrated liquid protein with expiration date of 15 May 2026.- one bottle of Rapid Dry skin protectant with expiration date of 10-03-2025.- one tube of Extra Strength Anti-Itch Cream with expiration date of 06/2024. These failures could prevent residents illnesses from being addressed by not getting the therapeutic benefit of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow the menu for three of three days reviewed for menu adherence. The facility failed to follow the lunch menu on 5/27/2026, 5/28/2026, and 5/29/2026. The facility failed to post menus visible for residents to see what is being served daily. These failures placed residents at risk for decreased intake, dissatisfaction with their meals, weight loss, and nutritional inadequacy.

Inspectors wroteBased on observation and interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when 1 of 5 staff observed for infection control failed to perform proper hand hygiene. CNA L failed to perform hand hygiene while passing meal trays from the hall cart to residents in their rooms. These deficient practices placed residents at risk for cross contamination and/or spread of infection.

Inspectors wroteBased on interviews and record review the facility failed to provide adequate supervision and assistance devices to prevent accidents for 1 of 6 (Resident #1) reviewed for accident hazards and supervision. The facility failed to ensure Resident #1 was properly secured in her wheelchair on 4/20/2026, which resulted in the resident slipping out of her wheelchair onto the floor of the vehicle and suffering a fractured toe and shoulder pain. This failure placed the residents at risk of serious harm and a diminished quality of life.

Inspectors wroteBased on interviews, observation, and record review, the facility failed to allow immediate access to residents by a state representative of HHSC in that:The facility's Administrator refused to allow a HHSC Employee to enter the facility to conduct a Priority One investigation; with a resulting outcome of delaying entrance on 3/3/2026 from 10:05 am through til 2:00 pm, a delay of 4 hours. This failure placed all 93 residents at risk of potential harm due to a priority investigation not being conducted to rule out immediacy.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for one of one kitchen reviewed for kitchen sanitation, in that: The facility failed to label, date and seal food items in the pantry, refrigerator and chest freezer on 3/3/2026. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #2 and Resident #3) of six residents review for resident rights. The facility failed to keep Resident #2's bell within reach to call for assistance. The facility failed to provide an alternative way for Resident #3 to call for staff assistance. These failures place residents at risk of not getting their needs met timely.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure resident rooms were adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for two (Resident #2 and Resident #3) of six residents reviewed for resident call system in that: Resident #2 and Resident #3 did not have a properly functioning call system in their room from 11/18/2025 to 01/29/2026. This failure placed residents at risk of being unable to obtain assistance for activities of daily living or in the event of an emergency.

Inspectors wroteBased on interviews and records review the facility failed to develop and implement a person-centered comprehensive care plan for each resident consistent with resident rights set forth that include measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. for one (Resident #1) of six residents reviewed for care plan. The Facility failed to include in Resident #1's care plan that she needed 2-person physical assist with transfer via mechanical lift. The facility failed to have an order for Resident #1 to be transferred via mechanical lift. This deficient practice placed Residents at risk for not getting the right interventions, risk for harm and hospitalization.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for mechanical lift transfer. The facility failed to ensure Resident #1 was transferred safely when CNA A transferred her by mechanical lift by herself on 01/29/2026. This failure placed residents at risk of injury. Review of Resident #1's face sheet printed 01/29/2026 reflected a [AGE] year-old female who was admitted on [DATE] with the following dx: [...]

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 1 of 1 kitchen reviewed for dietary services in that: The facility's dietary staff failed to effectively label and date items in the walk-in refrigerator. The facility failed to address the kitchen's air conditioning vents that were visibly soiled with a black substance. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to have 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 1 of 5 residents (Residents #1) reviewed for food and nutrition services.1. The facility failed to ensure Resident #1's personal refrigerator did not have a brown substance stuck to the bottom of the refrigerator and freezer along with a food encrusted butter knife. 2. The facility failed to ensure Resident #1's personal refrigerator had a temperature log. These deficient practices 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 provide a safe, clean, comfortable, homelike environment for 1 (Resident #1) of 5 Residents. The facility failed to clean food and dead fly larvae (maggots) from Resident #1s bed side table on 08/29/25. This failure could place residents at risk of living, and families visiting in an unclean and uncomfortable environment. Record review of Resident #1's undated admission record reflected a [AGE] year-old male who was admitted to the facility on [DATE]. Diagnosis included Alzheimer's disease (a progressive brain disease leading to memory loss), Diabetes Mellitus (elevated blood sugar), High Blood Pressure, and schizophrenia (a chronic mental health disease affecting a person's thoughts, feeling, and behaviors). [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for 3 (Resident #1, Resident #2, and Resident #3) of 9 residents reviewed for abuse and neglect. 1. The facility failed to provide continuous one to one monitoring for Resident #1 after repeated targeted aggressive behavior against Resident #2. An Immediate Jeopardy (IJ) situation was identified on 07/01/25 at 6:55 pm for failure #1. While the IJ was removed on 07/02/25 a 6:42 pm the facility remained out of compliance at a scope of isolated that with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. 2. The facility failed to ensure Resident #3 was not physically abused by MA F on 06/25/2025 when MA F grabbed Resident #3's wrist. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that residents received routine and emergency drugs and biologicals for 1 of 6 residents (Resident #3) reviewed for pharmacy services. The facility failed to give Resident #3 her Rivaroxaban 20mg (a medication used to prevent blood clots) tablet scheduled medication on 06/22/2025, 06/23/2025, 06/24/2025 and 06/25/2025. These failures placed residents at risk not receiving the therapeutic benefit or adverse reactions to prescribed medications. Record review of Resident #3's admission record, dated 07/02/2025, reflected a [AGE] year-old female originally admitted to the facility on [DATE] and last readmitted on [DATE]. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 3 residents (Resident #3) reviewed for significant medication errors. The facility failed to ensure Resident #3 was administered her Rivaroxaban 20mg tablet (a medication used to prevent blood clot formation to prevent a cerebral infarction, which is a blood clot blockage that impairs blood flow through the brain artery that can lead to permanent disability or even death) scheduled medication on 06/22/2025, 06/23/2025, 06/24/2025 and 06/25/2025. These failures placed residents at risk for complications, as well as jeopardize their health and safety.

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 (Resident #1) of 3 residents reviewed for accidents and hazards. The facility failed to ensure there was appropriate supervision on [DATE] when Resident #1, who resided on the secure unit, exited the secure unit, after RN A left the unit (to respond to a code after not being familiar with the CPR policy), and then one of the facility's side exits and got into the passenger seat of a parked fire truck in the parking lot. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:28pm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received care consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrates they were unavoidable, and a resident with pressure ulcers received necessary treatment and services to promote healing, prevent infection, and prevent new ulcers from developing for one 1 (Resident #3) of six residents reviewed for quality of care. The facility failed to complete weekly skin assessments, obtain wound care orders and a therapy consult for Resident #3, causing his wound to deteriorate. These failures placed the resident at risk of not receiving adequate care and services, pain, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #2) of two residents reviewed for medication pass, in that: The facility failed to ensure Resident #2 was administered his medications within the one hour before and one hour after timeframe. These failures placed residents at risk for not receiving therapeutic effect of their medications as ordered by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for the facility's one of one kitchen reviewed for physical environment. The facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior in the facility's only kitchen. These failures could affect residents by placing them at risk of contaminated food due to the lack of a well-kept kitchen environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infections when 1 of 5 staff (CNA A) observed for infection control failed to perform proper hand hygiene. CNA-A failed to perform hand hygiene while serving and assisting residents with their meal in the facility's only dining room on 5/29/2025. These deficient practices placed residents at risk for cross contamination and spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's call light was within reach on 05/16/2025. This failure could place residents at risk of their needs not being met.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation of resident property were reported immediately, but no later than 24 hours after the allegation was made to the State Survey Agency for 2 of 5 residents (Resident #1 Resident #2) reviewed for abuse. The facility failed to report within 24 hours to the State Survey Agency (HHSC - Health and Human Services Commission) that there was alleged physical abuse between Resident # 1 and Resident # 2 when staff reported to the ADM on 04/05/2025. Resident #2 pushed/hit Resident # 1 in the chest as they passed each other in the hallway on date 04/05.2025. This failure could place residents at risk for further abuse.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation to maintain an infection prevention and control program (IPCP) designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections in 1 of 2 dining rooms observed for infection control. in that: - Food items were not labeled and/or dated. Some food items that were labeled were out of date. - Dirty vents and vents with leaves in the kitchen. - Utensils in a dirty plastic drawer. Dirty fryer and grease in the kitchen. - Dirty Juice dispenser not cleaned. - Not all the food is being temped at lunch. - Blood on the walk-in floor. - Food temps not being taken. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to provide the residents or family group with a private space; and consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 resident council reviewed. The facility failed to provide a private meeting space for residents to conduct monthly resident council meetings. The facility failed to follow up on concerns and requests expressed in resident council meetings from January 2025 through March 2025. This failure placed residents at risk of not having the privacy needed to openly discuss their needs and preferences and have their preferences honored.

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents for 1 of 1 facility reviewed for environment. The facility failed to repair cracks and penetrations (holes) in residents' bedroom and bathroom walls, clean residents' toilets and bathroom floors, clean dust particles and dirt from the ceiling and air vents in residents' bedrooms, repair residents' bathroom toilet, clean residents' bedroom and bathroom walls, empty residents' trash in their bedrooms and bathrooms, properly repair residents' bathroom vents, and clean residents bedroom blinds, windows and window sills. This deficient practice could place residents at risk of not living in a safe, functional, sanitary and comfortable environment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 6 residents (Resident #68 and #55) reviewed for resident rights. The facility failed to ensure Resident's #68's call light was within reach on 03/17/25. The facility failed to provide Resident #55 with access to the call light when he was sitting in the middle of the room. This failure could place residents at risk of needs not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal medical records for 1 of 6 residents when reviewed for privacy (Resident #246). The facility failed to ensure the RN provided privacy by closing the laptop and leaving the laptop unattended in the hallway which displayed Resident #246's information after closing Resident #246's door and while performing wound care on Resident 246's right arm on 03/18/25 at 11:45 AM. These failures could place residents at risk of having medical information personal or care instructions exposed to others and misuse of personal information.

Inspectors wroteBased on interviews, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (Resident #73) of six residents reviewed for medications. The facility failed to indicate adequate diagnosis and monitoring for Seroquel (an atypical antipsychotic medication) for Resident #73. The facility failed to have a completed consent with justification of the appropriateness of an atypical antipsychotic medication for Resident #73. This failure could place residents on psychoactive medications at risk for adverse consequences such as impairment or decline of an individual's mental or physical condition.

Inspectors wroteBased on interviews and record review, the facility failed to obtain the hospice nursing documentation, most recent hospice plan of care specific to each patient, hospice election form, physician certification and recertification of the terminal illness specific to each patient, names and contact information for hospice personnel involved in hospice care of each patient, hospice medications information, hospice physician and attending physician orders for one (Resident #246) of six residents reviewed for hospice services and records. The facility failed to obtain the required hospice documentation for Resident #246 when he was admitted to hospice. This failure could affect residents by placing them at risk for services and treatments not being coordinated for end-of-life care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure its residents were free from abuse for 2 of 10 Residents (Resident #2 and Resident #3) reviewed for resident-on-resident abuse. 1. The facility failed to prevent Resident #1 from punching Resident #2, on his body, on 8/18/2024. 2. The facility failed to prevent Resident #1 from physically abusing Resident #3, with a wheelchair, on 8/22/2024. This failure could have placed the facility residents at risk of physical harm and mental anguish.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a CCP for 1 or 3 residents (Resident #1) reviewed for CCP. 1. The facility failed to implement care plan interventions for Resident #1, after Resident #1's physically abused Resident #2 on 8/18/2024, to protect other facility residents. This failure could have placed the facility residents at risk of physical harm and mental anguish.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation is made for 2 of 10 residents (Resident #1 on Resident #2) reviewed for abuse. 1. The facility failed to report physical abuse, from Resident #1 on Resident #2 on 8/18/2024, within 2 hours. 2. The facility failed to complete a 5-day provider investigation for the Resident #1 on Resident #2 abuse, which on 8/18/2024. This failure could have placed the facility residents at risk of physical harm and mental anguish.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents received services with reasonable accommodation of resident's needs and preferences for 1 of 1 facility reviewed for resident rights. The facility failed to ensure the phones were working consistently and receiving incoming phone calls. This failure could place residents at risk of not receiving calls from family, friends, or providers leading to anxiety, sadness, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of three residents (Resident #1 and Resident #2) reviewed for ADLs. The facility failed to ensure Resident #1 and Resident #2 received showers as scheduled. This failure could place residents at risk of a decline in hygiene, at risk for skin breakdown, loss of dignity, and decline in quality of life.

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 6 residents (Residents #1, #2, #3, and #4) reviewed for infection control, as indicated by: MA A and MA B did not clean and disinfect the wrist blood pressure monitor while using it on Resident #1, Resident # 2, Resident #3, and Resident #4. This failure could place the residents at risk of transmission of disease and infection.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs for 1 (Resident #1) of 1 resident reviewed for care plans in that: 1. The comprehensive care plan did not reflect Resident #1's behaviors of refusing HD along with interventions. 2. The facility failed to notify the kidney center on 05/09/24 and 05/11/24 about the resident refusing treatment and not making it to his appointments as reflected in the care plan. These failures could result in residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observation, interview and record review that facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is (A) significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) 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). On 5/11/2024 Resident #1 was admitted into the hospital due to a decline in health. Resident #1 was lethargic, unable to stand, skin was pale in color and fingertips were turning purple. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 1 of 13 residents (Resident #1) reviewed for nutrition and hydration. On 5/11/2024 Resident #1 was admitted into the hospital due to a decline in health. Resident #1 was lethargic, unable to stand, skin was pale in color and fingertips were turning purple. Resident #1 was diagnosed with severe dehydration and non-traumatic rhabdomyolysis (breakdown of muscle tissue that release a damaging protein into the blood). [...]

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, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse and resulted in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for three of seven residents (Residents #1, #2 and #3 ) reviewed for abuse and neglect . 1. The facility failed to report Resident #1's fall on 4/15/2024, which resulted in a facial injury, in a timely manner to the State . 2. [...]

Inspectors wroteBased on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations were thoroughly investigated 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, and if the allegation was verified appropriate corrective action was taken for one of six residents (Resident #1) reviewed for abuse and neglect . The facility failed to report, within five days, the results of an investigation of an allegation of Abuse and Neglect involving Resident #1 when she fell on 4/15/2024. This failure could place residents at risk for continued abuse or neglect without appropriate corrective actions being taken.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for dietary services. 1. The facility failed to seal food products in airtight containers, labels food products with product name, label food products with the open/discard date, and dispose of food products after discard date. 2. The facility failed to clean and sanitize the kitchen's only industrial can opener, food prep areas, and the area surrounding the facility's only dishwasher. This failure placed the residents at risk of ingesting food-borne pathogens.

Inspectors wroteBased on interviews, observations, and record review the facility failed to ensure each resident receives adequate supervision and assistive devices for one of twenty residents (Resident #1) reviewed for accidents. The facility failed to ensure Resident #1's coffee cup was positioned properly at the upper right of his plate which led to him knocking it over. Resident #1 sustained 2nd degree burns to his bilateral inner thighs from the hot coffee. An IJ was identified on 01/11/2024 at 4:10 PM. While the IJ was removed on 01/12/2024, the facility remained out of compliance at a severity level of actual harm and a scope of isolated harm due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. These failures placed all residents at risk for injuries, pain, and mental anguish.

Inspectors wroteBased on interviews and record review, the facility failed to follow regulations and a written policy on permitting residents to return to the facility after they were hospitalized , or placed on therapeutic leave, for 1of 8 residents (RES #6) who were reviewed for discharges. On 11/11/2023, the facility did not allow RES #6 to return to the facility after he was sent to the emergency room for acute care. This failure placed residents at risk for not receiving care and services to meet their needs upon therapeutic leave and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for one (room [ROOM NUMBER]) of four resident rooms reviewed for a clean and homelike environment, in that: The facility failed to ensure room [ROOM NUMBER] did not have spattered and smeared orange and brown substance on the wall by the bed and the room was free of a bitter foul odor. This failure placed residents at risk of decreased feelings of self-worth and a diminished quality of life.