Lampasas Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 1 (Resident #1) of 6 residents reviewed for accuracy of assessments. The facility failed to ensure the MDS assessment dated [DATE] was updated to reflect all of Resident #1's current functional abilities. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status.

Inspectors wroteBased on interview and record review, it was determined the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for one (Resident #1) of six residents reviewed for baseline care plans, in that: Resident #1 did not have a baseline care plan developed in 48 hours of his admission on [DATE]. This failure had the potential to cause residents to not be provided needed care to prevent injuries, feelings of helplessness and a diminished quality of life. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and hazards. The facility failed on 04/13/2026 to ensure Resident #1 received 2 person assist when transferred, by use of mechanical lift, when CNA A was observed on AEM operating the mechanical lift alone. This failure could place residents at risk for falls, or skin tears.

Inspectors wroteBased on interviews and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them for 1 of 5 (R#1) residents reviewed for medication administration. MA A failed to accurately administer R#1's p.m. medications on 02/11/26. R#1 was observed with 4 medications on her face. This failure could place residents at risk of not accurately receiving their medications, which could result in a change in condition. Record review of R#1's admission record, dated 02/13/26, reflected she was admitted to the facility on [DATE] and discharged from the facility on 02/11/26. [...]

Inspectors wroteBased on interview, observation 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 1 (Resident #1) of 3 residents reviewed for PASARR Level I screenings. The facility failed to ensure the PASARR Level 1 screening did not indicate a diagnosis of mental illness, Resident #1 had a diagnosis of bipolar disorder with an onset date of 09/17/2007. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on observations, the facility failed to prepare food in accordance with professional standards for food safety in the facility only kitchen reviewed for kitchen sanitation. DC A failed to sanitize her hands in between tasks while preparing puree and taking temperatures. This failure could have placed residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #12) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-A provided care for Resident #12. This deficient practice could place residents at risk for infection.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan consistent with resident rights and that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 (Resident #10) of 3 residents reviewed for comprehensive care plans. The facility failed to include Resident #10's tramadol pain medication in her care plan dated 11/20/25. This failure could lead to residents not receiving needed care and/or receiving improper care/treatment. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two of two residents reviewed for quality of care. The facility failed to provide Resident #1 with post-surgery pain medication for more than 48 hours after admission, provide enteral feeding and hydration for more than 19 hours after admission, and provide colostomy/ileostomy (an opening in the abdomen for feces to leave the body) care to avoid fecal leakage, skin breakdown, and hospitalization. The facility failed to provide Resident #2 with the proper care and assessment to identify an injury of unknown origin that resulted in a large bruise across her chest and breasts. An IJ was identified on 11/18/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #1) of 8 Resident reviewed for quality of care. The facility failed to ensure MA A notified LVN B on [DATE] when Resident #1's BP reading was 86/54 on [DATE], which is far from baseline. Resident #1 was sent to the ER on [DATE] and was diagnosed with Sepsis (a serious condition that occurs when the body has an extreme reaction to an infection leading to widespread inflammation and potential organ dysfunction.) and Hypotension (or low plod pressure is a condition where blood pressure is lower than 90/60 mm Hg. It can occur as a standalone condition or as a symptom of other health issues). Resident #1 died 2 days later while in the hospital. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 1 resident out of 10 residents (Resident #1) reviewed for Activities of Daily Living care. The facility failed to provide nail care to Resident #1 as her nails were long, jagged, and sharp. This deficient practice placed residents at risk of a decline in their hygiene, at risk of skin breakdown, a decreased level of satisfaction with life, and a decreased feeling of self-worth.

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 1 of 1 kitchen reviewed for dietary services in that: The facility failed to correctly label and date food, dispose of expired items within the expiration dates, and effectively store frozen items in sealed containers. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 (Resident #143) of 5 residents reviewed for resident rights and dignity. The facility failed to promote Resident 143's independence and dignity while assisting her to eat lunch in the dining room. This failure could place residents at risk for a loss of dignity, decreased self- worth, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services with a reasonable accomodation to 1 of 5 residents (Resident #143) by failing to equip the resident with a device 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. The facility failed to ensure Resident #143 was accommodated with a device to call for staff assistance. This failure could place residents at risk of not being able to get assistance when needed.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 5 residents (Resident #25) reviewed for comprehensive care plans. The facility failed to ensure Resident #25's comprehensive care reflected Resident #25 Advance Directive status of DNR (Do Not Resuscitate). This deficient practice could place residents at risk for receiving improper care and services due to inaccurate care plans.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a baseline care plan that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 10 residents (Resident #1) reviewed for baseline care plans. This failure could place the resident at risk of continuity of care and communication among nursing home staff, reduced resident safety, and reduced safeguards against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on observations, interviews and record reviews 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 1 of 10 residents (Resident #30) reviewed for resident rights; in that: The facility failed to ensure Resident #30's call light was within reach. This failure could place residents at risk of needs not being met.