Jourdanton Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #1) reviewed for incontinence care. The facility failed to ensure while providing incontinent care to Resident #1 on 07/27/2026, CNA-A cleaned the resident's suprapubic area (the area of the abdomen located below the umbilical region) and separated the labia when cleaning the resident's genital area. This failure could place residents who require incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #2) out of 3 residents reviewed for medical records. The facility did not ensure nurses document accurately on Resident #2's Treatment Administration Record on 07/03/2026 and 07/16/2026 regarding the resident's wound care. This failure could place residents at risk for missed treatments which could result in decline in healing and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of their personal and medical records for 1 of 4 resident (Resident #2) reviewed for resident rights. The facility failed to ensure CNAs A and B completely closed Resident #2's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents at risk of loss of dignity.

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 disease and infection for 1 of 4 resident (Resident #2) reviewed for infection control, in that: The facility failed to ensure CNA A sanitized between her fingers when sanitizing her hands, therefore not properly sanitizing her hands, while providing incontinent care for resident #2. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: A bag of broccoli in the freezer was opened. A tub of peanut butter had peanut butter around the rim of the bucket. A bin of flour was opened. A box with oranges had mold. These failures could place residents who received food and/or snacks from the kitchen at risk for food borne illness. Observation on 1/13/2026 at 9:41AM the freezer revealed a box folded close with the corners of the four flaps tucked under one another that allowed a gap in the center that revealed an open bag of broccoli, exposing it to air in the freezer. Observation on 1/13/2026 at 9:46AM the dry food storage was used as an office. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to dispose garbage and refuse properly for 1 of 2 dumpsters (dumpster #1) on the premises. Three doors on dumpster #1 were opened. This failure could place the facility at risk of pests and rodents that could cause contamination of the foods stored in the kitchen and place the residents at risk of infection and illness. Observations and interview on 1/13/2026 at 10:00AM revealed dumpster #1 had 2 sliding doors opened on the sides and one of the black doors that closed on the top of the dumpster was opened. The [NAME] said she knew the doors should be closed so animals could not get into the dumpsters and garbage pickup was every Monday. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 8 Residents (Resident #23) who was reviewed for call light placement. Nursing staff failed to ensure Resident #23's call light was within reach. Resident #23 asked for water and was not able to locate his call light because it was under the fall mat. This deficient practice could result in residents not being able to ask for assistance as needed.

Inspectors wroteBased on observation, interview and record review the facility failed to manage and account for the personal funds of the resident deposited with the facility for 1 of 1 Resident (Resident #41) reviewed for personal funds. The facility failed to disburse Resident #41's personal funds so that she could purchase incontinent supplies. This could contribute to feelings of frustration and helplessness for the residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident has a right to secure and confidential personal and medical records for 1 of 1 facility reviewed for confidentiality: in that: The facility staff left the laptop open, unlocked, and unattended on the MA cart with the screen turned on and the EMAR visible to resident records and medications. This deficient practice could place residents at risk for having their medical information being unnecessarily exposed and their personal privacy violated.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 2 of 6 residents (Residents #11, and #49), reviewed for quality of care. The facility failed to ensure Resident #11's nebulizer mask and mouthpiece attachment was enclosed in a container or bag when it was not in use. The facility failed to ensure Resident #49's oxygen concentrator filter was clean. This failure could place residents at risk of illness, allergies, and worsening of respiratory symptoms.

Inspectors wroteBased on observation, interview, and record review the facility failed to safeguard medical record information against loss, destruction, or unauthorized use to maintain accurate medical records for 1 of 4 (Resident #2) residents reviewed for change in condition The facility failed to document the of change of condition and transfer to the hospital for Resident #2. These failures could place the residents at risk of inadequate care and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them under an agreement for 1 of 5 Residents (Resident #1) whose records were reviewed for pharmacy services. 1. Nursing staff failed to contact the pharmacy to ask about the status of the pending order for Lyrica and consult with Resident #1's PCP to obtain a one-time order for Lyrica (pain medication) pending pharmacy delivery of the medication from 10/10/25 until 10/15/25. 2. LVN A failed to contact and consult with Resident #1's PCP and the pharmacy when Lyrica (pain medication) was not available for administration for Resident #1 per physician orders. This failure could place residents at risk of a decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of their personal and medical records for 1 of 1 resident (Resident #11) reviewed for resident rights. The facility failed to ensure CNAs H and I completely closed Resident #11's privacy curtain while providing perineal care for the resident. This deficient practice could place residents at risk of loss of dignity.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded for a fall with injury that occurred on 09/04/2025, on his admission MDS assessment, signed as completed on 9/11/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #2) reviewed for quality of care. The facility failed to complete weekly skin assessment for Resident #2 for 2 out of 10 weeks (week of 9/24/2025 and week of 11/06/2025) per the care plan and facility policy. This failure could place residents at risk of not receiving necessary medical care, harm, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and service to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #11) resident reviewed for incontinent care and catheter care. The facility failed to ensure CNA H retract Resident #11's foreskin (the retractable roll of skin covering the end of the penis) while providing incontinent care . This deficient practice could place residents at-risk for infection and skin break down

Inspectors wroteBased on observation, interview, and record review the facility failed to in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 2 of 4 residents (Resident #2 and Resident #3) reviewed for clinical records. The facility failed to document 10 occasions for Resident #2 and 1 occasion for Resident #3's medication administration of Cefinir, and antibiotic on multiple occasions. This failure could place residents at risk of not receiving the care and services needed.

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 disease and infection for 1 of 1 resident (Resident #11) reviewed for infection control, in that: 1. The facility failed to ensure CNAs H and I washed their hands before starting to provide incontinent care for Resident #11. 2. The facility failed to ensure CNA H sanitized his hands between change of gloves during incontinent care for Resident #11 . These deficient practices could place residents at-risk for infection due to improper care practices.

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 are thoroughly investigated and report the results of all investigations to the state survey agency within five working days of the incident for 5 (Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 8 residents reviewed for abuse and neglect. The facility failed to thoroughly investigate 4 separate facility reported incidents involving Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6 within five (5) days regarding allegations of abuse or neglect and submit a 3613-A of the findings. This deficient practice could place residents at risk of harm from neglect due to not having a thorough investigation done for facility reported incidents.

Inspectors wroteBased on interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 (Resident #3) of 3 residents reviewed for pharmacy services. The facility failed to ensure staff timely acquired and administered Resident #3's cefazolin (antibiotic used to treat and prevent bacterial infections. It is administered intravenously) per physician orders on 2/13/25 and 2/14/25. The failure could place residents at risk for exacerbation of health conditions, worsening of conditions, and physical/emotional discomfort.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 of 6 residents (Residents #1 and Resident #3) reviewed for medical records. 1. The facility failed to ensure Resident 1's use of a wander guard (electronic monitoring device) was accurately documented on the TAR (Treatment Administration Record). 2. The facility failed to ensure the ADON documented the administration of Resident #3's cefazolin (antibiotic used to treat and prevent bacterial infections. It is administered intravenously.) at the time of administration on the MAR. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 2 of 9 residents (Resident #1 and #2) reviewed for documentation. Resident #1's and Resident #2's electronic medical record did not contain complete and accurate documentation that CNA A (night shift) and CNA B (day shift) recorded in the March 2025 POC (records system) that both residents were given peri-care on 3/17/25 (night) and 3/18/25 (day). This failure could result in residents' records not accurately documenting interventions, monitoring, and information provided to the charge nurse or DON involving shift documentation of peri-care given to residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to be free from accidents for 1 of 5 residents (Resident # 196) reviewed for accidents and hazards. On 9/19/2024, Resident # 196 was not properly secured in the facility transport van and sustained a head laceration and a fractur to her right clavicle. The non-compliance was identified as past noncompliance. The IJ began on 9/19/2024 and ended on 9/19/2024. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of harm, serious injury, or death.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to offer a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for 1 (Resident #6) of 1 residents reviewed for diets. The facility failed to provide Resident #6 with large protein portions as ordered by his physician. This failure could affect all residents on therapeutic diets by placing them at increased risk for significant weight loss and malnutrition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 3 medication carts (the Treatment Cart) reviewed for medication storage, in that; The facility failed to ensure the Treatment Cart was locked when it was left unattended in the common area in front of the nurses' station, and then again left unlocked and unattended in the 200-hallway opposite of room [ROOM NUMBER]. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on observations, interviews and record reviews, 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 1 of 2 residents (Resident #12) with wounds observed for infection control, in that: The facility failed to ensure hand hygiene was initiated between glove changes during wound care for Resident #12 on 10/03/2024. This deficient practice could affect residents who required wound care by contributing to the bacteria load and/or cross contamination in the wound resulting in delayed healing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms or at least 100 square feet in single resident rooms in all of the resident rooms reviewed for room size, in that: The facility failed to ensure all resident rooms had the required minimum of 80 square feet per resident in rooms occupied by multiple residents. This failure could place residents who reside in these rooms at-risk for a limitation their ability to move around the room and a decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a full code resident with AED use during CPR as per facility policy for 1 (Resident #4) of 7 residents reviewed for Advanced Directives. The facility failed to provide a full code(full support which includes cardiopulmonary resuscitation (CPR), if the patient has no heartbeat and is not breathing.) for Resident#4 with AED use during CPR as per facility policy. The non-compliance was identified as past non-compliance (PNC). The PNC IJ began on [DATE] and ended on [DATE] . The facility had corrected the non-compliance before the state's investigation began on [DATE] at 9:30 AM. This failure could place residents at risk for not receiving correct CPR as per facility policy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an Infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 2 residents (Resident #5) reviewed for infection control, in that: While providing incontinent care for Resident #5 CNA A did not wash or sanitize her hands between change of gloves, before touching the resident's briefs and after cleaning the resident's buttocks' area. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure their medication error rate was not 5 percent or greater and had a medication error rate of 71.88% percent with 3 medications administration opportunities observed with 23 errors for 4 of 6 residents (Residents #12, Resident #13, Resident #32, and Resident #42) and 2 of 3 staff (LVN C and CMA E) reviewed for medication administration, in that: 1. LVN C did not administer the full dose of Resident #12's gabapentin and simethicone medications when she left residue in a medication up during a PEG tube medication administration. 2. CMA E did not administer Resident #13's sucralfate 2 hours after all other medications. 3. CMA E administered 9 of Resident #32's medications 2 hours after the order time. 4. CMA E administered 10 of Resident #42's medications 2 hours after the order time. [...]

Inspectors wroteBased on interview and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, for 1 of 16 residents (Resident #14) reviewed for resident rights, in that: Residents #14 was told they could not lay down at the living area table to sleep and was told to go sleep in her room. This failure could place residents needing assistance at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure housekeeping and maintenance services necessary to maintain a sanitary and comfortable interior for 2 of 16 residents (#19 and #24) reviewed for housekeeping and maintenance services in that: 1. Resident #19's had flies in his room. 2. Resident #24's floor, bed, and in room ac unit had debris. Flies were present in the room. An empty dignity bag was hanging from the bed touching the floor with debris around it for 3 days. These failures could place residents at risk of living with unclean, uncomfortable, un-homelike rooms and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #24) reviewed for incontinence/perineal care, in that: CNA D did not clean the urethral meatus or glans when providing peri care and catheter care to resident #24 and failed to sanitize her hands in between glove changes. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 of 5 aides (CNA D) reviewed for demonstration of skills and techniques necessary for residents' needs, in that: The facility failed to ensure nurse aide competency assessments for CNA D, reviewed, were completed, documented, and checked off. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.

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 to help prevent the development and transmission of infections for 2 of 5 staff (CNA D and CMA E) reviewed for infection control, in that: 1. CNA D did not sanitize her hands between glove changes. 2. CMA E touched the curtains and put on her gloves which contaminated her hands prior to administering eye drops to Resident #13. These deficient practices could place residents who receive wound care or catheter care at-risk for infections.