Kingsville Nursing and Rehabilitation Center

Inspectors wroteBased 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 1 of 1 dining rooms reviewed for infection control practices. The facility failed to ensure the CNA-A knew the correct way to perform proper hand hygiene. The facility failed to ensure CNA-A knew the correct way to handle residents' dining utensils. The facility failed to ensure CNA-A knew the correct way to wear a surgical mask to prevent the spread of infection. These failures and deficient practices could place residents at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 3 (Resident #1, #2, and #3) of 5 residents reviewed for infection control practices. The facility failed to ensure CNAs were aware of the correct technique and infection control practices when providing incontinent care to Resident #1. The facility failed to ensure Residents #2 and #3 had the appropriate PPE outside the residents' rooms. These failures could place residents at risk for cross-contamination and infection.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to develop the diabetic comprehensive care plan for Resident #1. The facility failed to implement fall mats listed in Resident #1's care plan. These failures could place residents at risk of receiving improper or inadequate care and services.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse, neglect, and misappropriation for 1 of 5 residents (Resident #1) reviewed for developing and implementing abuse and neglect policies and procedures.1. The facility failed to follow their policy to report to HHSC within two hours when Resident #1 alleged Resident #2 sexually assaulted him on 02/07/26.2. The facility failed to follow their policy to investigate an allegation of sexual abuse made by resident #1 on 02/07/26. This failure could place residents at risk for abuse/continued abuse and could lead to a diminished quality of life and psychosocial harm. Record review of Resident #1's admission record reflected an [AGE] year-old male admitted to the facility on [DATE] with hospice (end of life care). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from any significant medication errors for one of five residents (Resident #1) reviewed for medication errors. The facility failed to hold Resident #1's carvedilol (blood pressure medication) when Resident #1's blood pressure was outside of physician's parameters on December 12th and 22nd of 2025. This failure could place residents at risk for complications such as increased blood pressure, exacerbation of symptoms, and potential hospitalization.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure that residents were free from abuse for one of six (Resident #33) residents reviewed for abuse. The facility failed to ensure that the SW did not take Resident #33's DVD player away when he displayed unwanted behavior on 04/11/25. This deficient practice could put residents with unwanted behaviors at risk of not attaining or maintaining their highest practicable levels of mental and psychosocial wellbeing.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals properly and in locked compartments on 1 of 5 carts reviewed for storage of drugs and 1 (med-room [ROOM NUMBER]) of 2 medication rooms reviewed for storage. 1. The facility failed to ensure the WCN cart located on the 200 hall was locked when not in use. 2. The facility failed to ensure Resident #54's expired medications were disposed of in a timely manner. 3. The facility failed to ensure Resident #81 and Resident #54's medications were stored in the appropriate boxes for the residents. These deficient practices could affect residents who have medications on the wound care cart and in the medication rooms and could result in lost medications, drug diversion, or harm due to accidental ingestion of unprescribed medications.

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 kitchen reviewed for storage, preparation, and sanitation. The facility failed to ensure the juice gun nozzle was clean. The facility failed to ensure the juice gun nozzles were stored properly. The facility failed to ensure food was stored properly in refrigerator number 2. These failures could place residents who received meals and/or snacks from the kitchen risk for food contamination and food borne illness. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for one (Resident #61) of 4 residents reviewed for infection control practices, in that: The facility failed to ensure the WCN wore proper PPE during wound care for Resident #239 who required enhanced barrier precautions. The facility failed to ensure Resident #239's surgical incision did not come in contact with a potentially contaminated surface during wound care. These failures could place residents that require wound care at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of eight residents (Resident #2) reviewed for accidents and hazards. The facility failed to ensure a floor mat was in place beside Resident #2's bed as indicated on her current comprehensive care plan and current physician's orders. This failure could place residents at risk for an injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 5 residents (Resident #1) reviewed for pharmacy services. 1. The facility failed to clarify the blood pressure parameters for Resident #1's Hydrochlorothiazide (a diuretic that helps treat high blood pressure and fluid retention) orders for April and May of 2025. 2. The facility failed to administer Resident #1's Hydrochlorothiazide per the recommended and prescribed blood pressure parameters in April and May of 2025. These failures could place resident at risk for complications, as well as jeopardize their health and safety.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.

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 kitchen, in that: 1. The Dietary Manager was observed in the kitchen not wearing a beard hair restraint. 2. There were two 6.5 lb bags of sliced strawberries in the freezer that were not dated. 3. There was a bag of tostada chips in the kitchen store- room that was not labeled or dated. 4. There was an electrical outlet in the kitchen that did not have an attached cover on the outlet. 5. There was a ceiling vent in the dish-room that had rust on the sprinkler head and dirt on the ceiling around the vent. 6. There was a ceiling vent in the dish-room that had dirt particles and grease on the vent slats. [...]

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 infection for 1 of 5 residents (Resident #51) reviewed for infection control, in that: 1. CNA A and B failed to wash or sanitize their hands or change their gloves after touching items in close proximity of Resident #51 before starting incontinent care. 2. CNA B did not clean between her fingers with hand sanitizer while providing incontinent care. 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 transmit encoded, accurate, and complete MDS data to the CMS System for 1 (Resident #42) of 24 residents reviewed for MDS accuracy and completion, in that: Resident #42's Discharge MDS Assessment was not exported within 14 days of completion. This deficient practice could result in MDS inaccuracies.

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 communicable diseases and infections for 1 of 5 resident (Resident #1) reviewed for infection control, in that: The facility failed to ensure the PTD was wearing the appropriate PPE while in Resident #1's room, who was in isolation. This deficient practice could place residents at risk of infection for transmission of communicable diseases and a decline in health.