Jacinto Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review, the facility failed to have sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident by providing care including assessing, evaluating, planning and implementing resident care plans and responding to resident's needs for 1 (Resident #1) of 7 residents reviewed for nursing services. The facility failed to ensure that skin assessments were completed completely and correctly for Resident #1. This failure could place residents at risk of worsening skin conditions or infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13 %, based on 4 errors out of 29 opportunities, which involved 2 of 7 residents (Resident #59, Resident #58) and one of five staff (MA V) observed during medication administration.1. MA V failed to administer Resident #59's Gabapentin 100 mg (used in treatment for neuropathy) and Pentoxifylline Extended Release 400 mg (used in treatment for peripheral vascular disease) according to physician orders, the medication was administered over one hour after the prescribed time. 2. MA V failed to administer Gabapentin 100 mg to Resident #59 from Resident #59's own supply of medications. MA V administered a Gabapentin capsule taken from a supply belonging to CR #10.3. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 9 of 12 resident rooms and public areas reviewed for environment.1. The facility failed to ensure the floors were clean and not tacky, in the hallways where the following resident rooms were located: 202, 203, 204, 205, 206, 207, 222, 223 and 224.2. The facility failed to ensure the floor in the public restroom was clean and not tacky. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life. Observation on 02/18/26 at 1:00 PM revealed the hallway floors were tacky where the occupied rooms numbered: 202, 203, 204, 205, 206, 207, 222, 223 and 224. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition for 1 (Resident #1) of 6 residents (Resident #1) reviewed for foot care. The facility failed to obtain treatment orders and monitor the status of Resident #1's skin impairment to her toe. The facility failed to monitor and document the blood-tinged gauze present on Resident #1's toe on 2/17/26-2/18/26. This failure could result place residents at risk of in discomfort and/or infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers for 1 of 6 residents (Resident #12) reviewed for tube feeding. The facility failed to ensure Resident #12 received her enteral feeding, Jevity 1.5, at the rate assigned by the MD on 2/17/26 and 2/18/26. This failure could result in weight loss and dehydration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, 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 one of three medication carts (Medication Aide Cart 2-Front) reviewed for medication storage.1. The facility failed to keep residents' eye drop medications in their original containers/packaging. There was one box of Simbrinza 1%/0.2% (an eye drop used to treat glaucoma and high eye pressure) that had two resident name labels.2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the kitchen pantry and refrigerator located in the kitchen area that was reviewed for food procurement. The facility failed to ensure food items stored in the refrigerator were properly identified and dated when opened. The facility failed to train staff in identifying the importance of the sanitizing strips. The facility failed to discard expired food items found in the refrigerator. The facility failed to clean and sanitize the kitchen. The facility failed to repair a malfunctioning dishwasher temperature, resulting in inaccurate readings and the inability to verify proper sanitation of dishes. These failures could place residents at risk of foodborne illness, disease, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide housekeeping and the maintenance services necessary to maintain a clean, sanitary, safe, and comfortable environment for 7 of 10 resident rooms (Rooms #215, #216, #309, #311, #312, #313, and #314) reviewed for the environment. This failure could affect the health, safety and the dignity of the residents and other residents in the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a minimum of 80 square feet per resident for 2 of 6 multiple occupancy resident rooms (Rooms #311 and #314) reviewed for room size. Rooms #311 and #314 did not have the required 80 square feet per resident. These failures could place residents at risk of reduced living space and could affect their activities of daily living (ADLs).

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for 1 of 3 hallways, (Hall 200), conference room, and Resident #1 and #2's shared room. The facility had live flies in the room of Resident #1 and #2 located on Hall 200. The facility had live gnats in and outside the conference room located on Hall 200. This failure has the potential to place residents at risk for disease and a decline in their physical health.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure residents received adequate supervision for 1 of 5 residents (CR #1) reviewed for accidents. CR #1 eloped from the facility on 03/23/2025 while in the secured unit, through the window. CR #1 was found at a previous residence on 03/24/2025 and refused to return to the facility. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 03/23/2025 and ended on 03/24/2025. The facility corrected the non-compliance before the investigation, began on 10/14/2025. This failure could place the residents with exit seeking behaviors at risk for injury or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure Residents who are incontinent of bowel and bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extend possible for 1 of 5 residents (Resident #1) reviewed for incontinent care. CNA A failed to place the urine collection bag of the indwelling urinary catheter below Resident #1's bladder after transferring from bed to chair. The failure could place residents with indwelling urinary catheters at risk for infection from potential backflow of urine into the bladder.

Inspectors wroteBased on interview and record review, the facility failed to implement their written policies and procedures that prohibit and prevent abuse for 1 (Resident #1) of 7 residents reviewed for reporting abuse. -The facility failed to implement their written policy of abuse when facility staff failed to report to the Administrator when Resident #1 was found in bed tightening his call light wire around his neck and was sent to the hospital for a possible suicide attempt on 12/26/2024. -The facility failed to implement their written policy of abuse when the facility failed to notify the state agency of the allegation of abuse. This deficient practice could place residents at risk of continued and/or unrecognized abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 24 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to other officials including to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #1) of 7 residents reviewed for reporting. -The facility staff failed to report to the Administrator when Resident #1 was found in bed tightening his call light wire around his neck and was sent to the hospital for a possible suicide attempt on 12/26/2024. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 90 days (9/21/24, 9/29/24, and 10/20/24) reviewed for RN coverage. The facility failed to ensure they had RN coverage for at least 8 consecutive hours on 9/21/24, 9/29/24, and 10/20/24. This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 17% based on 5 errors out of 29 opportunities which involved 2 of 9 residents (Resident #34 and #20) and 2 of 4 staff (MA A and LVN B) reviewed for medication administration. MA A crushed and administered Divalproex DR (a delayed release medication used to treat seizure disorders and mental/mood conditions) and Oxybutynin ER (an extended-release medication used to reduce bladder spasms and treats overactive bladder) to Resident #34 on 12/4/24. Delayed and Extended-release formulations should not be crushed. MA A administered Resident #48's Sertraline (used to treat depression) to Resident #34 on 12/4/24. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 2 of 8 residents (Resident #56 and Resident #20) reviewed for privacy in that: 1. LVN A failed to provide privacy while administering medications via g-tube (a surgically placed device used to give direct access to the stomach for supplemental feeding, hydration or medicine) to Resident #56 by not closing her privacy curtain on 12/04/2024. 2. LVN B failed to provide privacy while administering an IV flush to Resident #20 by administering his IV flush in the middle of the hallway on 12/04/2024. This failure could place residents at-risk of loss of dignity due to lack of privacy.

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 2 of 8 residents (Resident #20 and #56) reviewed for infection control. -LVN A did not wear appropriate PPE when administering medication via peg-tube care (PEG tubes allow you to receive nutrition through your stomach) to Resident #56 who was on enhanced barrier precautions (an infection control intervention designed to reduce transmission of multidrug-resistant organisms in nursing homes) on 12/4/24. -LVN A de-clogged (remove or clear a blockage) Resident #56's g-tube using an oxygen key that was retrieved from her pocket on 12/4/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight for 1 of 5 residents (Residents #2) reviewed for nutrition. - The facility failed to follow up on the Registered Dietitian's recommendations for Resident #2's severe weight loss. This failure could place residents at risk for weight loss and decline in health status.

Inspectors wroteBased on observation, 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 1 of 6 residents (Resident #2) reviewed for pharmacy services. MA K administered Resident #4's Gabapentin (used to prevent and control seizures, and to relieve nerve pain) to Resident #2. This failure could place residents at risk of misappropriation of property and medication errors.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure residents received care consistent with professional standards of practice, to prevent pressure ulcers, promote healing, and to prevent new ulcers from developing for 1 (Resident #3) of 18 residents reviewed for pressure ulcers. - The facility failed to perform adequate skin assessments to identify pressure injuries for Resident #3, who was non-ambulatory and wheelchair bound. - The facility failed to identify and treat Resident #3's stage 2 (wound goes through skin and looks like a blister or ulcer but does not go through deep tissues ) and stage 3 (wound goes through deep tissue and fat but does not expose bone) pressure injuries. An Immediate Jeopardy (IJ) was identified on 9/4/2023. The IJ template was provided to the facility on 9/4/2023 at 1:00pm. [...]

Inspectors wroteBased on observation and interview the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest, practicable, physical, mental, and psychosocial well-being of each resident for 1 (Resident #3) of 18 residents reviewed for Administration. - The Administrator failed to ensure nursing staff were performing weekly skin assessments on Resident #3 and other residents at the facility, causing Resident #3 to get facility acquired Stage 2 (wounds extends through skin and looks like a blister or ulcer but does not extend through deeper tissue) and Stage 3 (wound extends through deep tissue and fat but does not expose bone) pressure wounds. [...]

Inspectors wroteBased on observation, interview, and record, review the facility, failed to ensure maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; environment for residents in the secured unit in rooms # 145, 215, 216, 310, 312,&room [ROOM NUMBER] room [ROOM NUMBER] had scraped wall by the sink and uneven floor on the entrance from 215 room [ROOM NUMBER]'s bathroom had an uneven floor. room [ROOM NUMBER], and 303 had a strong urine smell and bathroom floor was uneven. room [ROOM NUMBER] and 311 had an uneven floor. room [ROOM NUMBER]' bathroom floor bear covering off the floor. Hole behind the door. room [ROOM NUMBER]'s bathroom floor was partially covered half of the floor covering was off. Face board off the wall. room [ROOM NUMBER]'s had a dirty drinking cup. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 1 of 3 residents (Resident #27) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Resident #27. The facility failed to provide Resident #27 with showers according to shower schedule. These failures could place residents at risk of having decreased quality of life and loss of dignity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received necessary services to maintain good personal hygiene for 4 (Residents #27, #3, #23, and #64) out of 18 residents reviewed for ADL care. - Facility staff failed to provide scheduled showers to Resident #27, and Resident #3. - Facility staff failed to provide services to keep Resident #23 clean, shaved, and nails trimmed. - Facility staff failed to provide timely incontinent care to Resident #64. These failures could place residents who were unable to carry out ADLs, at risk of not receiving necessary personal hygiene, showers, and incontinent care, which could lead to skin breakdown, pain, and infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received medically related social services to attain or maintain the highest practicable physical well-being for 1 of 6 residents (Resident #27) whose records were reviewed for medically related social services, in that; Resident #27 was not assisted by a social worker with obtaining a viable means of communicating his thoughts, feelings, and preferences to staff. This deficient practice could result in loss of dignity and having unmet needs due to insufficient medically related social services.

Inspectors wroteBased on interview, and record review the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed for unnecessary medications. (Resident #64) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #64's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.

Inspectors wroteFACILITY Kitchen Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food procurement in that: - The facility failed to discard expired/undated food items in the kitchen refrigerator. These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness.

Inspectors wroteBased on observation and interview, the facility failed to designed or equipped resident's room in the secured unit (Room # 214, 215, 216, 304, 203, 304, 305, 306, 307, 308,309,310, 311, 312, 314 315) to have ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains to assure full visual privacy for each resident. All rooms in the secured unit had half visual cotton that provide partial privacy\covering to residents and responsible party that chooseice to visit. This failure could placed residents at risk of feeling insecure or uncomfortable in their rooms.

Inspectors wroteBased on observation, interview, and record review the facility failed 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 9 (Resident bathrooms 214, 215, 217, and 218, and Resident rooms 229B, 308A, 308B, 313A, and 313B) out of 12 resident bathrooms and resident rooms reviewed for call lights. - The call light did not turn on when pushed for resident rooms 229B, 308A, 308B, 313A, and 313B. - The bathroom emergency light did not turn on when pulled for resident bathrooms 214, 215, 217, and 218. These failures could place residents at risk of falls and/or injuries if they are unable to get staff assistance when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident receives an accurate assessment, reflective of the resident's status at the time of the assessment for 3 of 3 (Residents #27, #40, #15) residents reviewed for accuracy of assessment. -The facility failed to accommodate Residents #27's communication deficit by providing an alternative method to accurately complete his quarterly MDS assessment dated [DATE]. -The facility failed to accurately assess Resident #27 for his mental illness (qualifying diagnoses) on his quarterly MDS assessment dated [DATE]. -The facility failed to accurately identify Resident #40 with mental illness which had been identified on PASRR level II evaluation on her admitting MDS assessment dated [DATE]. - The facility failed to accurately complete Resident #15's admission MDS dated [DATE]; [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet residents' medical, nursing, and mental and psychosocial needs for 2 of 18 residents (Residents #24, and #31) whose care plans were reviewed. - Resident #24 was not care planned for PTSD. - Resident #31 was not care planned for ROM and OT. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 2 (Residents #31, and #21) out of 18 residents reviewed for care plan accuracy. - Resident #31 did not have her wound care added to the care plan. - Resident #21 did not have ROM, Restorative Carrot, or his Enteral Feed (provides nutrition through a tube into the stomach) added to the care plan. These failures could place residents at risk of not receiving care and services needed to maintain their highest practicable quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident (Resident #4) with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 3 residents reviewed for limited range of motion. The facility failed to ensure that RCNA U provided passive range-of-motion appropriately and for prescribed amount of time for Resident #4. These failures could place residents with contractures at risk for decrease in mobility, range of motion, and contribute to worsening of contractures.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 of 2 CNAs (CNA Z) serving and assisting residents in the dining area. - The facility failed to ensure dining room assistant (CNA Z) sanitized his hands between providing dining room assistance. This failure could place residents at risk for cross contamination.

Inspectors wroteBased on record review and interview the facility failed to include in the facility's admission packets provided to residents and their representative on admission, inform regarding arbitration agreement if they chose to have one or not. The facility failed to ensure that current and potential residents were informed in a clear and understandable language about the facility's arbitration process. This failure could place the residents and their representatives at risk of being uninformed about their rights regarding binding arbitration and less able to defend their rights related to disputes, controversy or claims arising out of or related to the services provided by the nursing facility.