Llano Nursing and Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to immediately consult with the resident's physician and the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status for 3 of 6 residents (Resident R#1, R#2, R#3) reviewed for notification of changes. The facility failed to ensure R#1's physician and residents' representative were notified on 2/27/26 and on 3/5/26 when resident alleged staff were abusive to her. The facility failed to ensure R#2 and R#3's physician and resident representative were notified on 2/20/26 when R#2 and R#3's were within hearing distance of a staff verbal altercation. These failures could place residents at risk of not receiving appropriate medical treatment, which could result in a decline in health.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food storage and sanitation. 1. The facility failed to properly store, label, and date all food items located in the walk-in refrigerator, freezer and in the dry food pantry area on 9/02/2025 and 9/03/2025. 2. The facility failed to discard expired food items located in the walk-in refrigerator and in the dry food pantry area on 9/02/2025 and 9/03/2025. 3. The facility failed to ensure the trash containers were covered with lids on 9/02/2025 and 9/03/2025. These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and document a care plan conference following a quarterly or annual MDS (minimum data set) for 6 (Resident #22, Resident #5, Resident #2, Resident #6, Resident #8, Resident #30) of 10 residents reviewed for care plan conferences. The facility failed to complete a comprehensive care plan for Resident # 30 in the required timeframe after the completion of the comprehensive MDS dated [DATE]. The comprehensive care plan for Resident # 30 was due to be completed by 8/31/25. The facility failed to conduct a care conference for Resident #22, Resident #5, Resident #2, Resident #6, and Resident #8. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to accommodate each resident's allergies, intolerances, and preferences for 4 of 7 residents (CR #1, CR # 2, CR # 3, CR # 4) reviewed for food and nutritional services. The facility failed to ensure CR # 1, CR # 2, CR # 3, and CR # 4 meal preferences were met- By not offering breakfast meal alternate.-By not offering a daily meal alternate for the lunch and dinner meals.-By not honoring food preferences on resident meal cards. These failures could place residents at risk of not having their food preference needs met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity in a manner and environment that promoted the maintenance or enhancement of quality of life for 1 (Resident #10) of 10 residents reviewed for dignity. 1. The facility failed to ensure Resident #10 was appropriately groomed without a brief showing during mealtime. This failure could place residents at risk of diminished dignity and affect their quality of life.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide special eating equipment for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 of 3 residents (Resident #4) reviewed for special eating equipment and assistance when consuming meals. The facility failed to ensure Resident #4 was provided with a Sippy Cup with built in straw to meet Resident #4's need for assistance while eating. This failure could place residents at risk for harm from weight loss, diminished independence, and self-esteem.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure results of the most recent surveys such as (surveys, certifications, and complaint/incident investigations) of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to survey were readily available to examine for 1 of 1 facility in that: 1. The required state survey documents were not posted in a location readily accessible and visible to all residents, their legal representatives, or family members as required.2. The facility failed to maintain the survey binder; the binder failed to include 3 previous years of required state visit results from 6/28/23, 1/17/25, and 4/9/25. This failure could place all residents of the facility at risk of limited' rights to access information regarding the facility's compliance with state and federal requirements.

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate advance directives for 2 of 4 residents (Residents #1 and #2) reviewed for advanced directives. 1. The facility failed to ensure that Resident #1's out of hospital do-not-resuscitate (OOH-DNR) was dated by the physician and was witnessed by two people or notarized. 2. The facility failed to ensure Resident #1 had a designated medical power or attorney (MPOA) documented via MPOA form. 3. The facility failed to ensure that Resident #2's out of hospital do-not-resuscitate (OOH-DNR) included second signatures by witnesses and the second signature of a guardian/agent/proxy/relative. [...]

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment requirement for one [dietary manager] of one kitchen staff reviewed for qualifications. The facility failed to have a qualified Dietary Manager. This failure could affect all residents whose nutritional needs are the food services manager responsibility placing them at risk of foodborne illness weight loss and compromising their health and well- being.

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 HR staff was not wearing hair restraints while in the kitchen. The trashcan next to the handwashing station was overflowing and without liner. The Ice machine was dirty. An open and overflowing trash container was stored next to the ice machine. The ice scoop was stored with the mop pads, mop bucket, and brooms located over the Ice machine. The [NAME] failed to change gloves and perform hand hygiene after touching the trash can lid. The dishwasher water temperature was below the recommended temperature. The facility did not document temperatures for the food, dishwasher and refrigerators. [...]

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 5 of 5 residents (Resident #6, Resident #8, Resident #11, Resident #13, and Resident #23) reviewed for resident rights. The facility failed to ensure Resident #6, Resident #8, Resident #11, Resident #13, and Resident #23's call lights was within reach on 08/05/2024, 08/06/2024 and 08/08/2024. This failure could place residents at risk of needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had comfortable temperatures in the building, putting residents at risk of heat related illnesses. The facility failed to maintain comfortable and safe temperature levels when the temperatures in the facility exceeded 81 degrees. These failures could place residents at risk due to being in an environment that is unsafe or uncomfortable.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater for when the facility had a medication error rate of 7.14% based on 2 of 28 opportunities, which involved 2 of 4 residents (Resident #24 and Resident #1) and 1 of 2 MA's (MA E) observed during medication administration. A) Resident #24 had a physician order for Lisinopril 20mg 1 tablet by mouth every day, with special Instructions to hold the medication if his systolic blood pressure was less than 110 and hear rate less than 60. MA E failed to check Resident #24's vital signs before administering the medication. B) Resident #1 had a physician order for Losartan Potassium tablet 50mg 1 tablet by mouth every day with a parameter to hold medication if her blood pressure was less than 140/90. [...]

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 for one (1) of one (1) kitchen reviewed for food safety and sanitation The facility failed to ensure food storage containers were properly secured, sealed, and labeled. This failure placed residents at risk of foodborne illness.

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 #12, Resident #24, and Resident #21) of 6 residents reviewed for infection control. A) The facility failed to maintain infection control for Resident #12 during Foley catheter care by failing to perform appropriate hand hygiene while providing care. B) The facility failed to maintain infection control for Resident #24 during wound care by failing to perform appropriate hand hygiene while providing care. [...]

Inspectors wroteBased interviews and record review, the facility failed to ensure each resident was free from abuse, neglect, exploitation, and misappropriation of resident property for one (1) of five (5) residents reviewed. The facility failed to prevent the misappropriation of Resident #1's Ozempic 4MG/3ML Pen (1MG). Ozempic is a GLP-1 agonist that assists with weight loss and blood sugar regulation. This failure placed the resident at risk for not receiving their prescribed medication. Findings Include: Record review of Resident #1, on August 5, 2024, through August 7, 2024, reflected a 55yo male who was admitted to the facility on [DATE], with diagnoses including in part: Cellulitis, Diarrhea, Vitamin D deficiency, Hyperlipidemia, Morbid (severe) Obesity due to excess calories, Type 2 Diabetes with unspecified complications, Pain, and Muscle Wasting and Atrophy. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 2 of 9 residents (Resident #21 and Resident #12) who were reviewed for accuracy of assessments. Resident #21's MDS was coded as having an indwelling catheter which had been discontinued. This failure placed residents at risk of incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review,The facility failed to provide 1 of 3 (Resident #9) with care and services related to activities of daily living. Resident #9 had to wait an extended amount of time to get assistance with feeding. The facility failed to ensure that Resident #9 was feed his lunch in a timely manner. This failure placed residents at risk for not receiving adequate care and services to prevent infection, injury, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 1 of 2 residents (Resident #12) reviewed for Foley catheter care received appropriate treatment and services to prevent urinary tract infections. The facility failed to follow infection control protocols while providing Foley catheter care for Resident #12. This failure placed residents at risk for urinary tract infections, urosepsis, and even death.

Inspectors wroteBased on observations, record reviews and interviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for one (1) of one (1) facility reviewed for environment The facility failed to repair a cracks or gaps between the wall and floor moldings in a resident's room, failed to repair a penetration (hole) in a resident's bedroom wall, clean dust particles and dirt from the ceiling of a resident's room, replace a missing toilet tank lid in a resident's room, remove and replace molded flooring in a resident's bathroom that was warped and folding away from the walls due to liquid saturation from urine, water or both. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse and neglect for 2 of 16 residents (Residents #1 and #2) reviewed for abuse/neglect. The facility failed to take sufficient protective measures after Resident #1 made verbal threats to other residents and was involved in multiple physical altercations with other residents. The facility failed to train staff in resident -to-resident altercations and failed to update Resident #1's care plans to include interventions for behaviors and resident altercations. An Immediate Jeopardy (IJ) was identified on 12/14/23. The IJ template was provided to the facility on [DATE] at 6:21 pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 16 residents (Residents #1 and #3) reviewed for care plans. Resident #1 and Resident #3 did not have completed comprehensive care plans for resident-to-resident behaviors and resident-to-resident altercations. An Immediate Jeopardy (IJ) was identified on 12/14/23. The IJ template was provided to the facility on [DATE] at 6:21 pm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one (Resident #27) of two residents reviewed for catheter care. LVN A inserted a foley catheter into Resident #27 urethra instead of re-inserting in his suprapubic stoma site and caused trauma and bleeding to the urethral region. This failure caused trauma and bleeding to the urethral region of Resident #27 and has the potential to affect all residents with catheters.

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 one of one kitchens reviewed for sanitation. The Dietary Manager failed to ensure all foods were labeled and dated. The Dietary Manager failed to ensure the dish machine was functioning at the proper temperature to sanitize dishes. CK K failed to reheat or discard a food item measured to below the minimum temperature required for serving. These failures placed residents at risk of foodborne illness.

Inspectors wroteBased on observations, interview, and record review the facility failed to provide maintenance services necessary to ensure resident had the right to a safe, clean, comfortable, and homelike for 3 (#15, #33, #35) of 38 residents reviewed for homelike environment. The facility failed to ensure the Resident #15, # 33 and #35 had a properly functioning toilet. This failure could lead to residents experiencing a decline in their psychosocial wellbeing.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents who were unable to carry out activities of daily living received the necessary services to maintain goo personal hygiene for one (Resident #31) of six residents reviewed for activities of daily living. The facility failed to provide regular baths to Resident #31 consistent with his needs and choices . This failure could place residents at risk for decreased hygiene, skin issues, and mental anguish.