Harker Heights Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish for 5 of 7 residents (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for quality of life. The facility failed to ensure nursing staff provided scheduled showers for Resident #2 according to his ADL care plan goal. The facility failed to ensure Resident #3, Resident #4, Resident #5, and Resident #6 were provided with perineal care and showers according to their ADL care plan goals. These failures could place residents at risk of decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for medical records. The facility failed to ensure RN A documented oxygen saturation assessment on 6/13/2026 according to the physician order in Resident #1's medical records. This deficient practice could place residents at risk of not receiving proper care due to incomplete and inaccurate records.

Inspectors wroteBased on, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 18 residents (Resident #1) reviewed for ADL care. The facility failed to ensure Resident #1 was provided incontinent care from 11:30 p.m. until 5:50 a.m. on 06/11/2026. This failure could place residents at risk of infection, skin breakdown and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, 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 1 of 3 medication carts (MC #1) reviewed for drug storage and labeling. The facility failed to ensure MC #1 was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 7 residents (Resident #1) for medical records. The facility failed to ensure Resident #1's skin tear cleaning was documented completed in the electronic medical record for 04/07/2026, 04/08/2026, and 04/13/2026. These failures could place residents at risk for the possibility of not verifying the needed care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters reviewed for garbage disposal. The facility failed to ensure the dumpsters were free from debris on 4/14/26 and on 4/15/26. The facility failed to ensure that 2 dumpsters were closed/covered on 4/14/26, 4/15/26 and 4/26/26. CK H failed to close/cover the dumpster after using it on 4/15/26. These failures placed residents at risk of being exposed to rodents and pests.

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 need of each resident for 2 of 6 medication carts (*the medication cart designated for use on the 100 Hall and the medication cart designated for use on the 200 Hall) reviewed for pharmacy services. The facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation at each shift change for the medication cart designated for use on the 100 Hall and the medication cart designated for use on the 200 Hall. This failure could place residents at risk of drug diversions and could result in diminished health and well-being. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately after the allegation was made for 1 of 5 (Resident #131) reviewed for resident abuse in that: RN E failed to report an allegation of verbal abuse made by Resident #131 on 4/03/2026. This failure could place residents at risk for on-going abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all allegations of abuse were thoroughly investigated for 1 of 5 (Resident #131) residents reviewed for resident abuse. The facility failed to investigate an allegation of abuse made by Resident #131 on 4/03/2026. This failure could place residents at risk for on-going abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's psychosocial needs for 1 of 5 (Resident #130) reviewed for care plans. The facility failed to ensure that Resident #130's care plan included interventions to address her psychosocial behaviors. This failure placed residents at risk of dwelling in a disruptive environment.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 2 of 7 residents (Resident #26 and Resident #107) reviewed for grooming. The facility failed to provide showers to Resident #26 in compliance with his shower schedule. The facility failed to provide ADL facial hair care to Resident #107. This deficient practice could place residents at risk of decline in skin integrity and psychological well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with the comprehensive person-centered care plan and the residents' choices for 5 of 13 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for quality of care. The facility failed to implement interventions, according to the comprehensive plan of care, to check and change on rounds and as needed to keep Resident #1, Resident #2, Resident #3, Resident #4 and Resident #5's skin clean and dry. The failure placed residents with self-care deficit, falls, and skin concerns at risk of decline or decrease in their quality of life and quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure drugs were stored properly and only authorized persons had access for 1 (MC #1) of 3 med carts reviewed for drug storage and labeling. The facility failed when MC #1 was in an unsecured location, unlocked, and was accessible to staff, residents and passers-by. This failure could place residents at risk of ingesting medications that was not prescribed to them leading to sickness. During an observation of MC #1 on 2/28/26 at 10:00 AM, revealed it was unattended, unlocked and accessible to staff, residents, and passers-by in the main lobby area. The locking mechanism was protruding outward on the medication cart. Neither the RN, nor the LVN saw the surveyor open the drawers and take pictures. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for 1 of 3 residents (Resident #1) reviewed for room or roommate changes. The facility failed to ensure Resident #1, and her RP received written notice prior to moving Resident #1 to another room. This failure could place residents at risk of having their resident rights violated and being moved into another room without notice.

Inspectors wroteBased on observation, interview and record review the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for 1 (Resident #1) of 25 residents reviewed for smoking. The facility failed to implement their policy that smoking for team members was permitted only in approved designated areas. This failure could place residents at risk of an unsafe smoking environment, accidents, harm and long-lasting health concerns centered around secondhand smoke.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure that the resident environment remained safe, clean, comfortable, and homelike including keeping the facility comfortable and safe temperature levels. Facilities initially certified after October 1, 1990, must maintain a temperature range of 71 to 81 F; for 1 of 1 memory care unit. The facility failed to maintain comfortable and safe temperature levels in the memory care unit when the local temperatures were at 97 Degrees Fahrenheit (F) and the temperature inside the memory care unit was 93 degrees (F) on 08/09/2025. An IJ was identified on 08/09/2025. The IJ template was provided to the facility on [DATE] at 8:47pm. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents who were unable to carry-out activities of daily living received necessary services to maintain personal hygiene for three of four (Resident #1, Resident #2, and Resident #3) residents reviewed for ADL care. 1. The facility failed to shave the underside of Resident #1's chin hair that was approximately 1 cm in length.2. The facility failed to shave the underside of Resident #2's chin hair that was approximately 1 cm in length.3. The facility failed to shave the underside of Resident #3's chin hair that was approximately 1 cm in length. This deficient practice could place residents at risk of a decline in self-confidence, isolation, low self-esteem, general happiness, and satisfaction, and feeling undignified. 1. [...]

Inspectors wroteBased on observations, 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 food labeling and storage in that: The facility failed to ensure the foods were labeled and dated in the kitchen refrigerator. This deficient practice could place residents at risk of foodborne illness. An observation on 7/02/2025 at 9:17 AM of the facility's only refrigerator revealed the following: - Salad greens in a metal container covered with clear, plastic wrap did not have a label containing the opened on and discard by dates. - Pasta noodles in a metal container covered with tinfoil did not have a label containing the opened on and discard by dates. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 1 (Resident #1) of 5 residents reviewed for pain recognition and management. The facility failed to ensure staff accurately assessed Resident #1's pain levels after falls in January and February 2025. Staff used a numerical pain scale instead of a pain ad assessment on Resident #1, who was unable to verbalize his pain level. This deficient practice could place residents at risk of serious injury, pain, being misdiagnosed, receiving improper care and services, not treated timely, effectively, and consistently.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure a resident's environment remained free of accident hazards and a received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for assistance devices in that: NAIT T did not provide Resident #1 with an assistive device (modified cup with lid) when serving coffee to prevent an avoidable accident from occurring. NAIT T served Resident #1 coffee in a standard mug which resulted in Resident #1 spilling the coffee onto her left hand and the table due to her tremors and spastic movements in both arms. The facility failed to ensure NAIT T was knowledgeable on how to locate the Kardex to determine what assistive devices were required during meal services to prevent accidents. An IJ was identified on 02/04/25. [...]

Inspectors wroteBased on Observation, Interview and Record Review, the facility failed to determine that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled (a system of recordkeeping that ensures an accurate inventory of medication by accounting for controlled medications that have been received, dispensed, administered, and/or, including the process of disposition) for )4 of 6 Narcotic Count Sheets reviewed for Change of Shift Narcotic Counts. The facility failed to ensure all controlled medications were accurately reconciled at the start and end of each shift. This failure could place residents at risk of misappropriation by drug diversion and could result in diminished health and well-being. [...]

Inspectors wroteBased on observations, 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 4 of 10 (Resident # 30, Resident #50, Resident #108, and Resident #190) residents observed for dignity. 1. The facility failed to ensure Resident #30, Resident #50, and Resident #108 were assisted with feeding in a dignified manner. 2. The facility failed to promote Resident #190's dignity while dining when staff did not serve her lunch tray for approximately 45 minutes after tablemate was served. These failures could place residents at risk of experiencing humiliation, degradation, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive and at a safe and appetizing temperature for residents who consumed foods orally from the only kitchen in the facility in that: 1. a) The test tray of the lunch meal on 02/06/25 was lukewarm, unappetizing in appearance (no seasoning observed, and soggy roll on the plate), not cooked well (related to beef and pasta noodles) and lacked seasoning and flavor. b) The facility failed to provide palatable food that was attractive or appetizing to residents' who complained the food did not look or taste good. 2. The facility failed to follow the puree diet recipe. The puree scramble eggs recipe required three tablespoons and one teaspoon of food thickener. There was not a recipe for oatmeal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure DC K used proper hand hygiene during food preparation. 2. The facility failed to ensure DC L wore a beard guard when standing over food prep table. This failure could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observations, 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 # 30, and Resident #80) reviewed ADL care. 1. The facility failed to ensure Resident #30 and Resident #80 nails were cleaned, trimmed, and did not have any rough edges. This failure could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 2 of 7 residents (Resident #400 and Resident #188). 1. ADON A observed Resident #400 sliding out of the bed and walked out without aiding the resident with bed mobility. 2. The facility failed to ensure a qualified staff fed Resident #188. These deficient practices could place residents at risk for injury, harm, and low sense of self-worth.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for two (2) of ten (10) residents (Resident # 50 and Resident # 241) reviewed for food allergies. The facility failed to honor Resident #50's food preference according to her meal ticket and failed to ensure Resident #50 was not served beef, which her meal ticket reflected she disliked. The facility kitchen failed to honor Resident # 241's food allergies according to her meal ticket and served her products containing gluten (oatmeal, blueberry muffin, dinner roll, and egg noodles) which her meal ticket stated she had an allergy to gluten. This failure placed the resident at risk of consuming a food allergen and of receiving and consuming foods not of their preferred preference which could result in diminished health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 3 residents (Resident #57) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-G and CNA-J provided perineal and catheter care for Resident #57. This deficient practice could place residents at-risk for spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's RP when there was a significant change in the resident's physical status for 1 of 3 (Resident #1) reviewed for change in condition. The facility failed to ensure Resident #1's RP was notified when he was sent out to the hospital for low blood pressure on 01/27/2025 while at his dialysis treatment. This failure could place residents at risk of their responsible party not being involved in ensuring safety.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for one (Resident #1) of four residents reviewed for medication errors. The facility failed to: -Ensure Resident #1's order for insulin was instated upon admission from the hospital on [DATE]. -Ensure Resident #1's medication orders were accurate as she was being administered two anti-seizure medications in which she did not have a diagnosis for which resulted in a sudden change in consciousness/responsiveness and she had to be sent to the hospital. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 12/03/24 at 5:19 PM and an IJ template was given. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for one (Resident #1) of five residents reviewed for pressure injuries. The facility failed to instate wound treatment orders for Resident #1 after she was admitted from the hospital after a hip fracture requiring surgery on 10/18/24 until 10/22/24. When she was admitted there was shearing to her sacrum and after not receiving treatment the wound was a stage III. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 12/03/24 at 5:19 PM and an IJ template was given. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 2 of 2 Activity Director (AD) reviewed for qualified professionals, in that: The facility failed to have a qualified AD to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to notify the resident representative(s) when there was an accident involving the resident which results in injury and had the potential for requiring physician intervention for 1 (Resident #1) of 5 residents RP's reviewed for incidents. The facility failed to notify Resident #1's RP that staff observed Resident #1 had an injury of unknown origin. Staff observed Resident #1 had a black eye on 10/27/24 at 1:30 PM and didn't know how Resident #1 sustained the injury. Resident #1's RP was not notified until 10/27/24 at 7:39 PM. The facility failed to notify Resident #1's RP that an incident happened with Resident #1 on 10/25/24. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident #1) of 5 residents reviewed for ADL care. The facility failed to ensure Resident #1's wheelchair was clean. This deficient practice could place residents at risk of neglect, infection, and a diminished quality of life.

Inspectors wroteBased on observations, interviews and record reviews , the facility failed to ensure that all alleged violations were reported immediately or not later than 24 hours for 1 (Resident #1) of 5 residents reviewed for incidents. The facility failed to report to the SA an incident where Resident #1 was found with a black eye on 10/27/24. This deficient practice could place residents at risk of abuse and/or neglect.

Inspectors wroteBased on observation, interview and record review, the facility must develop and implement a comprehensive person centered care plan for each resident. 1. The facility failed to ensure Resident #65's interventions encouraging wearing footwear to help prevent falls were in place. 2. The facility failed to ensure Resident #78 was encouraged to wear footwear to prevent falls during her behavior of continuous walking. Progress notes reflected a history of falls on 10/24/22 and 11/07/22 (no interventions listed to limit fall risk) These failures could place residents at risk of falls and of not receiving care according to their needs.

Inspectors wroteBased on, interviews, and record reviews the facility failed to ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the residents' goals, and preferences, to wear and be able to use the prosthetic device for one (Resident #119) of seven residents reviewed for orthotic devices, in that: The facility failed to follow a physician's order, written on 8/22/2023 for Resident 119 to schedule an evaluation for a prosthesis. By the time the survey was being conducted the appointment had not been scheduled yet This failure could place residents at risk for health status decline, impaired mobility, without the support and therapeutic effects of prostheses devices.

Inspectors wroteBased on observation, Interview and record review the facility failed to maintain oxygen therapy equipment in accordance with their policy. Residents #69, #2, #28, #195, #197, #12 and #98 had oxygen equipment and tubing in their rooms undated and unserviced . This failure could place residents at risk of exposure to infectious bacteria/viruses in the tubing because of unknown use.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 3 of 4 medication carts (300/500 nurse med cart, 200/300 nurse med cart, and 100 treatment/nurse cart) reviewed for medication storage. The facility failed to properly label and date three insulin pens in the 300/500 nurse med cart. The facility failed to properly date one insulin pen in the 200/300 nurse med cart. The facility failed to properly label one insulin pen in 100 treatment/nurse cart. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store foods properly and maintain a sanitized food preparation area for the facility's only kitchen, which was reviewed for dietary services. 1. The facility failed to properly store, seal, and date food in the facility's walk-in refrigerator and freezer. These failures placed residents at risk of exposure to food borne pathogens.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #59, Residents #68, and Residents #111) and 1 of 1 staff (MA Y) reviewed for infection control. The facility failed to ensure multi-use equipment was properly cleaned between each resident. This failure could place residents at risk for spread of infection and cross contamination during medication administration.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity in a manner that promotes maintenance of his/her quality of life and recognized their individuality for two (Resident #1 and # 9) of 7 residents reviewed for resident rights in that: 1. The CTA fed Resident #1 while standing next to her. 2. LVN C referred to Resident #9 who requires assistance with feeding, as a feeder. These failures could place residents who needed feeding assistance at risk for lacking a dignified existence and unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan that provided effective and person-centered care of individualized resident care needs for 1 (Resident # 337) of 6 residents reviewed for person-centered care planning. 1. The care plan was initiated 8 days after Resident #337 was admitted . 2. The care plan only addressed activities; the care plan did not address goals, physician orders, dietary orders, therapy services, or social services. This failure could place newly admitted residents at risk for unmet needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident environment remained as free of accident hazards as was possible for one out of three residents (Resident #74) reviewed for hazards in that: Resident #74 was observed to have disinfectant sprays and wipes on the counter of her sink in her room .

Inspectors wroteBased on interview and record review the facility failed to ensure residents who used psychotropic drugs received gradual dose reductions, unless clinically contraindicated, for 1 of 4 residents (Residents #8) reviewed for unnecessary medications. The facility failed to ensure Resident #8 received gradual dose reductions (GDR) for Buspirone and Zoloft. These failures could affect residents on psychoactive medications, by placing them at risk for possible adverse side effects, adverse consequences, and decreased quality of life.

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 The facility failed to ensure food was stored properly in the dry storage area and walk-in refrigerator. The deficient practice placed residents who were served from the kitchen at risk for health complications and foodborne illnesses.

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 investigated, and the results of all investigations were reported to the State Survey Agency, within 5 working days of the incident for One (Resident #2) of six (6) residents reviewed, in that: The facility failed to report, within five days, the results of an investigation of an allegation of Misappropriation of Property by Resident #2 when her debit card was compromised. This failure placed residents at risk for continued abuse or neglect without appropriate corrective actions being taken.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring and administering of medications to meet the needs for one (Resident #1) of six residents reviewed for pharmacy services, in that: The facility failed to reorder Resident #1's seizure medication three days prior to running out and failed to follow up on the order, causing her to miss one dose in the evening on 12/10/2023. This failure placed residents at risk for medical complications, decreased quality of life and hospitalization

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 7 residents (Resident #3) reviewed for call lights in that: Resident #3 was observed in their room with call lights not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in injury or needs not being met.

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 13 of 18 residents (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, #10, #11, #12 and #13) reviewed for infection control. 1. The facility failed to isolate or test for COVID-19 for roommates (Residents #2, #4,and #6) of COVID-19 positive residents after the roommates were exposed to COVID-19. 2. The facility failed to ensure signs and symptoms of COVID-19 were documented for Residents #2, #4 and #6 during the period following exposure. 3. LVN C, HK D and CNA E failed to ensure they donned CDC-recommended PPE when they entered rooms of COVID-19 positive residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choices for 1 of 6 (Resident #3) residents reviewed for self-determination. The facility failed to honor Resident #3's Power of Attorney's request to change to a different Pharmacy. This failure could place residents who want to change pharmacies at risk for financial hardship, lack of self-determination, and unmet needs.