Lakeshore Village Nursing and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 2 of 5 residents (Resident #1 and Resident #4) reviewed for PASARR Level I screenings.1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #1 and Resident #4. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis PTSD (post-traumatic stress disorder) with an onset was present upon Resident #1 and Resident #4's admission.2. The facility did not complete a 1012 form to update Resident #1 and Resident #4's PASARR Level 1 with the new diagnosis. [...]

Inspectors wroteBased on interviews, record reviews, and observations, the facility failed to ensure food was stored in accordance with professional standards for food safety. The facility failed to ensure food was labeled and dated correctly in the refrigerator and freezer on 04/20/26. This failure could place the residents at risk of foodborne illnesses.

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 help to prevent the development and transmission of communicable diseases and infections for 3 of 3 residents (Resident #132, Resident #120, and Resident #58) reviewed for infection control. LVN A failed to disinfect the blood pressure cuff between residents (R#58, R#132, R#120) while performing medication administration. This failure place residents at risk for cross contamination and the development of infections.

Inspectors wroteBased on observation and interviews the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 1 days reviewed (4/21/2026) reviewed for nurse staffing posting. The facility failed to post accurate daily staffing information on 4/21/2026. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on interviews and record reviews, 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 on 03/03/2026 at 09:04 am to conduct a Priority One investigation. This failure placed all 123 residents at risk of potential harm due to a P1 investigation not being conducted to rule out immediacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision that could prevent accidents for 1 of 1 resident (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1's safety when OT was inattentive due to using her phone. This failure could place residents at risk of experiencing accidents and injuries.

Inspectors wroteBased on interview and record review the facility failed to immediately notify Resident #1's Responsible Party and practitioners when there was a significant change the resident's physical status (a deterioration in health) for one of five residents (Resident #1) reviewed for resident rights. The facility failed to inform Resident #1's Responsible Party when he refused to eat or drink from dinner on 4/9/2025 to breakfast on 4/11/2025. The resident was sent to the ER on [DATE] with altered mental status, high heart rate resulting in a diagnosis of Acute encephalopathy [altered brain function], Acute renal failure [decreased blood flow to the kidneys] and profound dehydration. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 5/8/2025 at 12:25 pm; the facility was notified and given an IJ template. [...]

Inspectors wroteBased on interview and record review the facility failed maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not a possible or resident preference indicated otherwise and is offered sufficient fluid intake to maintain proper hydration and health for one of five (Resident #1) residents reviewed for nutrition and hydration. The facility failed to ensure Resident #1 maintained acceptable parameters of nutritional status as demonstrated by Resident #1 refusing meals and hydration from dinner on 4/9/2025 to breakfast on 4/11/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menus met the nutritional needs of residents in accordance with established national guideline, were prepared in advance, were followed or appropriate substitutions were made, and reviewed by the facility's dietitian or other clinically qualified nutrition professional for nutritional adequacy for 1 of 1 kitchen reviewed for menu accuracy. 1) The facility failed to ensure the DM created a menu in advance and the menu had reviewed and approved by the regional dietitian for the special incentive lunch meal served in the dining room. 2) The facility failed to ensure [NAME] H served adequate portion sizes for residents during the lunch meal on 02/18/2025 when he did not use the correct scoop size and served food portions with his hands. [...]

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 the facility's only kitchen and two of two nourishment rooms reviewed for food and nutrition services. 1) The facility failed to close food product bags in the three-door freezer to prevent exposure to air. 2) The facility failed to label and date food items in the side-by-side refrigerator, freezer, and the two nourishment refrigerators. 3) The facility failed to ensure that one of their three-door freezers was maintained at acceptable temperatures which resulted in frozen foods thawing out and then re-freezing without being discarded. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat residents with respect and dignity for one (Resident #11) of six residents reviewed for dignity. The facility failed to speak to Resident #11 in a way that promoted her dignity and self-worth. This failure could place resident at risk of a decline in their sense of dignity, level of satisfaction with life, and feeling of self-worth.

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 8 residents (Resident's #112, #72, and #99's) reviewed for resident rights. The facility failed to ensure Resident's #112 and #99's call light was within reach on 02/18/25 and 02/19/25. The facility failed to ensure Resident #72's call light was within reach on 02/19/25. 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 the resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for four of six residents (Resident #11, Resident #43, Resident #53, and Resident #108) whose care was reviewed. The facility failed to allow Residents #11, #43, #53, and #108 to enjoy the salad bar that was served in the dining room because they either preferred to eat in their rooms or were bed ridden. This failure could place residents at risk of diminished feelings of self-worth and/or diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident received and the facility provided food that accommodated resident preferences for 4 of 12 residents (Resident #9, Resident #11, Resident #43, and Resident #53) reviewed for food preferences. The facility failed to ensure Resident #9's lunch tray excluded gravy, in accordance with her dislikes which were listed on her meal ticket, on 02/20/2025 when the facility served Resident #9 two hamburger patties covered in brown gravy. The facility failed to ensure Resident #11's lunch tray included margarine and sweet and low, in accordance with her meal ticket as well as her preferences, (which were not listed on her meal ticket), on 02/18/2025, 02/19/2025, and 02/20/2025 and failed to include her coffee or tea on her lunch tray on 02/19/2025. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents were given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living (ADLs) for 1 of 4 residents (Resident #231) reviewed for ADL abilities. Resident #231's glasses were dirty and had built-up grime present to both lenses on 02/19/25. This deficient practice could place residents who required assistance at risk for not receiving care and services to meet their needs and avoid ADL decline.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological's were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for two of five medication carts observed in that: Medication carts #1 and #2 were left unattended and unlocked. This failure could allow residents, staff and visitors unsupervised access to prescription and over-the-counter medications.

Inspectors wroteBased on interviews and record review, the facility failed to implement their written policies and procedures regarding prohibiting and preventing abuse for one (Resident #1) of ten residents reviewed for developing and implementing abuse and neglect policies. The facility failed to implement and utilize facility abuse, neglect, exploitation, or misappropriation - reporting and investigating policies when they did not report to local, state, and federal agencies (as required by current regulations) allegations sent by a LPN via text message to the administrator. In the text, the LPN revealed she believed that Resident #2 ejaculated on Resident #1. The facility failed to identify and assess all possible incidents of abuse and investigate and report all allegations of abuse within timeframes required by federal requirements. [...]

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 for 1 of 10 residents screened for abuse (Resident #1). The facility failed to immediately report to the State Agency (within 2 hours) an allegation sent by an LPN via text message to the administrator that she believed that Resident #2 ejaculated on Resident #1. This deficient practice delayed the investigation for the allegation and could have placed residents at risk for abuse and could have resulted in undetected abuse and/or decline in feelings of safety and well-being or psychosocial harm.

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 kitchen sanitation. The facility failed to ensure [NAME] A, Dishwasher C, and DA B wore hairnets and beard restraints when cooking, preparing, or assembling food. This failure could place residents who received meals and/or snacks from the kitchen at risk of foodborne illness due to physical contamination.

Inspectors wroteBased on observation, 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 needs of each resident and to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 2 of 7 residents (Residents #2 and 3) reviewed for pharmaceutical services. 1. The facility failed to administer medications (dicyclomine, Eliquis, Zoloft, lactulose, levetiracetam, and enalapril maleate) to Resident #2 on time on 05/09/24, 05/10/24, 05/11/24, 05/12/24, 05/13/24, 05/14/24, and 05/15/24. 2. [...]

Inspectors wroteBased on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 6 of 6 administrative staff responsible for monitoring and implementing the facility policy and procedures for 1 of 1 facility reviewed for Administration. 1. The Medical Director, NP, DON, and ADON failed to monitor routine laboratory results for residents on an anticonvulsant medication for seizure management. 2. The DON and ADON failed to ensure nursing staff had the appropriate competencies related to an LVAD (life-saving device). 3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for residents' needs for 8 of 8 nurses (LVN G, E, KK, CCC, GGG, NNN, OOO, and RN D ) reviewed for nursing services. 1. The facility did not ensure nursing staff was trained and educated on the LVAD (a device that is used in the treatment of end-stage heart failure). 2. The facility did not ensure nursing staff was trained on complications to monitor for Resident #231's LVAD. 3. The facility did not ensure nursing staff obtained MAP (average calculated blood pressure in an individual during a single cardiac cycle) pressures and documented them appropriately on the MAR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:07 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 5 of 12 residents (Resident's #12, #17, #43, #61, and #65) reviewed for laboratory services. 1. The facility did not ensure Resident #61 had his routine Keppra, Tegretol, and Depakote levels monitored as ordered by the physician. 2. The facility did not ensure Resident #43 had her routine topiramate and Keppra levels monitored as ordered by the physician. 3. The facility did not ensure Resident #12 had her routine primidone and phenobarbital levels monitored as ordered by the physician. 4. The facility did not ensure Resident #65 had her routine Depakote and phenytoin (Dilantin) levels monitored as ordered by the physician. 5. The facility did not ensure Resident #17 had his routine phenytoin (Dilantin) levels monitored as ordered by the physician. [...]

Inspectors wroteBased on observations, interviews, and record reviews 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 7 of 7 residents (Resident's #25, #68, #91, #107, #111, #127, #330, ) and 5 out of 15 staff (CNA O, CNA PP, CNA SSS, MA A, and RN D) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility did not implement antibiotic orders for Resident #127, who had signs and symptoms of an UTI, that had not resolved with treatment. 2. The facility failed to identify a resistant organism that was cultured from Resident #127's urine. 2a. The facility failed to ensure contact isolation precautions were ordered and implemented for Resident #127. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #54) of 3 resident reviewed for pressure ulcer. The facility failed to prevent Resident #54 from developing 2 unstageable pressure ulcers. The facility's failure could affect the prevention of pressure ulcers, affect residents with pressure ulcers, and put them at risk for worsening the wound and infection.

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 safety in the facility's only kitchen. The facility failed to ensure: *Food items were dated and sealed appropriately. *Expired food items were discarded. *The can opener was clean. *The microwave was clean *The juice nozzles were clean *The ice maker was clean *The mixer was clean *The deep fryer was clean *Hairnet worn correctly *Hydrion test strips (test strips used to measure the concentration of chemicals in sanitizing solution) were not expired. *Ecolab chlorine test strips (test strips used to measure the concentration of chemicals in sanitizing solution) were not expired These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 7 of 7 meetings ( May 2023, June 2023, July 2023, August 2023, September 2023, October 2023, and November 2023) reviewed for QAPI. 1. The facility did not ensure the Infection Control Preventionist attended their QAPI meeting in May 2023, July 2023, August 2023, September 2023, October 2023, and November 2023. 2. The facility did not ensure the DON attended their QAPI meeting in June 2023. These failures could place residents at risk for quality deficiencies being unidentified, infections, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on interviews and record review the facility failed to develop the baseline care plan within 48 hours of admission for 3 of 6 residents (Resident #231, Resident #330, and Resident #333) reviewed for baseline care plans. 1. The facility failed to ensure Resident #333 had a baseline care plan completed within 48 hours of admission 2. The facility failed to ensure Resident #330's baseline care plan was signed by an RN. 3. The facility did not ensure Resident #231 baseline care plan was completed within 48 hours of admission and signed by an RN. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop or implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 8 of 33 residents reviewed for care plans. (Resident's #12, #25, #65, #101, #105, #107, #111) 1. The facility did not implement a care plan for Resident #12's seizure disorder. 2. The facility did not implement a care plan for Resident #65's seizure disorder. 3. The facility failed to ensure Resident #107's physician's order for 1800ml fluid restriction was implemented. 4. The facility failed to ensure Resident #25's comprehensive care plan addressed his incontinence of bladder and sippy cup. 5. The facility failed to ensure Resident #105's Apixaban (also known as Eliquis an anticoagulant medication) was included in his care plan. 6. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to meet professional standards of care, for 3 of 6 residents (Resident #2, Resident #16, and Resident #40) reviewed for professional standards with medication administration. 1. The facility failed to ensure MA A performed hand hygiene while administering medications to Resident #2, Resident #16, and Resident #40. 2. The facility failed to ensure Resident #16 was administered the correct dose of Depakote (medication used to treat mood disorders). The facility failed to ensure Resident #16 was administered Medrol (steroid medication). These failures could place residents at an increased risk for inaccurate drug administration, not receiving the care and services to meet their individual needs, and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 1 secured unit and 2 of 24 residents reviewed for activities on the secured unit. (Resident's #106 and #117) 1. The facility failed to ensure Resident #106, and Resident #117 received activities to meet their interests. 2. The facility failed to ensure activities were performed in the secured unit. 3. The facility failed to ensure the activity calendar was posted in the secured unit. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident and hazards as possible and provided supervision interventions to prevent avoidable accidents for 1 of 4 residents (Resident #111) reviewed for falls, and 1 of 2 smoking areas (secured unit smoking area), and 1 of 5 shower rooms reviewed (Hall 400 shower room). 1. The facility failed to ensure Resident #111 had her physician ordered fall intervention a fall mat beside her bed. 2. The facility did not ensure a metal container was available in the secured unit's smoking area to empty the ashtrays. 3. The facility failed to ensure the shower room door on the Hall 400 would closed securely. These failures could place residents at risk of injury from accidents and hazards.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 5 of 10 (Residents # 48, #35, #6, #34, and #93) residents reviewed for respiratory care. 1. The facility failed to properly store the handheld nebulizer (HHN) and date tubing for Resident # 48 and Resident #35. 2. The facility did not ensure Resident #6 had an order from the physician to receive oxygen. 3. The facility failed to administer oxygen at 2 liters per minute via nasal cannula as prescribed by the physician for Resident #34. 4. The facility failed to ensure Resident #93's oxygen concentrator and filter were clean and free from debris. These failures could place residents requiring respiratory care at risk for respiratory infections or complications.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 4 of 33 residents (Residents #52, Resident #62, Resident #115, and Resident #339) and 1 of 1 facility reviewed for pharmacy services. 1. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2. The facility failed to keep periodic reconciliation of Resident #339's Tramadol 50 mg tablets (controlled pain medication). 3. The facility failed to ensure MA C documented on the MAR and narcotic record the administration of Resident #52's Acetaminophen-Codeine 300-30 mg (controlled pain medication). 4. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 33 residents (Resident #16 and Resident #105) and 1 of 5 medication carts reviewed for drugs and biologicals. 1. The facility failed to ensure the Secured Unit medication cart was secured and unable to be accessed by unauthorized personnel. 2. The facility failed to ensure Resident #16's medication card matched the order for her Depakote (medication used to treat mood disorder). 3. The facility failed to ensure Resident #105's nasal spray was stored properly. These failures could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 8 of 32 residents (Resident #15, #42, #65, #95, #100, #105, 111, and #333) and 1 of 1 meal (lunch meal) reviewed for dietary services. The facility failed to provide palatable food served at an appetizing temperature or taste to residents who complained the food was not hot and did not taste good. The facility failed to ensure Resident #111 received fortified foods. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow their own established smoking policy for the 1 of 2 smoking areas (secured unit) reviewed for smoking policies. The facility did not ensure a metal container with a self-closing cover device was available in the secured unit's smoking area to empty the cigarette butts. This failure could place residents at risk of an unsafe smoking environment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 33 residents (Resident #34) reviewed for resident rights. The facility did not ensure Laundry Aide F knocked, introduced herself, and explained what she was doing prior to entering Resident #34's room. This failure could place residents at risk for diminished quality of life, loss of dignity and loss of self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 33 residents (Resident #68) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #68's call light was within reach. This failure could place residents at risk for unmet needs and decreased quality of life. Findings Included: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 1 of 33 residents (Residents #61) reviewed for advanced directives. The facility did not ensure Resident #61's OOH-DNR included the legal guardian's signature, date, and printed name at the top of the form. The facility did not ensure Resident #61's OOH-DNR included the Notary information at the top of the form. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, clean, and comfortable environment for 2 of 71 rooms reviewed. (Room #'s 45 and 331) 1. The facility failed to ensure resident room [ROOM NUMBER]'s heating unit was working. 2. The facility failed to ensure Resident #331's TV cable outlet was not out of the wall. These failures could place the residents at risk for a diminished quality of life and a diminished well-kept environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 6 residents (Resident #52) reviewed for grievances. The facility did not ensure a grievance was completed for Resident #52's complaint of his television's poor reception being snowy. This failure could place residents at risks of grievances not being addressed or resolved promptly and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #63) reviewed for discharge MDS assessments. The facility failed to ensure Resident #63's discharge MDS assessment was completed and transmitted. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for 1 of 33 residents (Resident #105) reviewed for comprehensive care plans. The facility failed to ensure Resident #105's care plan was updated to indicate he no longer had a foley catheter. These failures could place residents at increased risk of not having their individual needs met, unnecessary procedures/treatment, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 2 of 7 residents (Resident #'s 44 and 71). The facility failed to ensure Resident #44's fingernails were free of a black colored material. 1) The facility failed to ensure Resident #71's fingernails were trimmed and free of a black colored material. 2) These failures could place residents at risk for and a decreased quality of life.

Inspectors wrote2. Record review of Resident #68's face sheet dated 12/14/2023, indicated Resident #68 was a [AGE] year-old male admitted to the facility on [DATE], with diagnosis which included unspecified sequelae of cerebral infraction (residual effects or conditions produced after the acute phase of an illness or injury has ended), type 2 diabetes mellitus without complications (closely manages their type 2 diabetes, they can reduce their risk of developing any complications), and hypertension (when the pressure in your blood vessels was too high (140/90 mmHg or higher). Record review of Resident #68's quarterly MDS assessment dated [DATE], indicated Resident #68 had a BIMS score of 1, which suggested severe cognitive impairment. The MDS assessment indicated Resident #68 was always incontinent of bowel and bladder. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that resident who wereare trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 6 residents (Resident #65) reviewed for trauma-informed care. The facility did not ensure Resident #65's trauma screening was completed upon admission to the facility. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 6.25%, based on 2 errors out of 32 opportunities, which involved 1 of 6 residents (Resident #16) reviewed for medication administration. The facility failed to ensure MA A administered the correct dose of Depakote (medication used to treat mood disorders) on 12/12/2023. The facility failed to ensure MA A administered Resident #16's Medrol (steroid medication) on 12/12/2023. These failures could place residents at risk of not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist residents in obtaining routine and emergency dental services to meet the needs of 1 of 33 (Resident #118) residents reviewed for dental services. The facility did not ensure Resident #118 received dental services for missing dentures. This failure could place residents at risk for oral complications, and/or weight loss, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 of 3 (Resident #25) residents reviewed. The facility failed to provide Resident #25's physician-ordered sippy cup with each meal tray. This failure put residents at risk for decreased fluid intake, dehydration, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually for 1 of 1 facility. The facility did not update their facility assessment when they admitted Resident #231 with a LVAD (a device that is used in the treatment of end-stage heart failure). This deficient practice could affect the resident by not having the necessary resources to ensure appropriate care is provided.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 residents (Resident #48) reviewed for hospice services. The facility failed to maintain Resident #48's hospice binder. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.