Longhorn Village

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to organize and participate in resident groups in the facility for 32 of 32 residents reviewed for resident rights.1. The facility failed to ensure resident council met on a regular basis.2. The facility failed to ensure a private space was provided for resident council meetings and failed to take reasonable steps to make residents aware of upcoming meetings in a timely manner.3. The facility failed to ensure the resident council met without (invited) staff present. These failures could place residents at risk of not being able to organize resident groups without interference to discuss and offer suggestions about facility policies and procedures affecting care, treatment and quality of life, support each other and plan and participate in activities. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 32 residents' bedrooms (Resident #4) reviewed for a homelike environment. 1. The facility failed to ensure Resident #4's room did not have a hole in the wall. 2. The facility failed to ensure Resident #4's bathroom toilet's water did not run continuously. These failures could place residents at risk of not having a safe, comfortable, and homelike environment with comfortable sound levels. Record review of Resident #4's admission Record, dated 05/14/26, reflected a female who was initially admitted to the facility on [DATE] and readmitted to the facility on [DATE]. Resident #4 was her own responsible party. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen. The facility failed to ensure food safety by not consistently monitoring, discarding expired food, not labeling and dating food items in the kitchen, and keeping chemicals out of the kitchen prep area. These failures can place residents at risk for foodborne illness. Observation in the kitchen on 5/12/2026 at 9:15 AM of REF 1 reflected the following: -Lemon juice with an expiration date of 4-12-2026-Shredded cheese in a Ziplock bag with no open or use by date. -Clear container with an unknown sauce with no open or use by date on the container. -Clear container of chopped garlic with an open date of 4-30-2026 and a use by date of 5/7/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible and systematically organized for 1 (R#17) of 32 residents reviewed for medical records. R#17 did not get treatment for her right forehead scab from 05/05/26 through 05/13/26. This failure placed residents at risk of not receiving appropriate supplies and services necessary for their needs. Review of R#17's admission Record, dated 05/12/26, reflected she was initially admitted to the facility on [DATE], readmitted to the facility on [DATE], and had a responsible party. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 (R#17) of 32 residents reviewed for treatment and care. The facility failed to provide treatment to R#17's right forehead scab from 05/05/26 through 05/13/26. This failure could place residents at risk of not receiving needed care and services that are resident-centered. Review of R#17's admission Record, dated 05/12/26, reflected she was initially admitted to the facility on [DATE], readmitted to the facility on [DATE], and had a responsible party. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 (R #9) of 32 residents reviewed for medication storage. A red pill was on the ground in the hallway in front of R#9's room on 05/12/26. This failure could place residents at risk their medications not being safe and secure. Review of R#9's admission Record, dated 05/14/26, reflected she was admitted to the facility on [DATE] and she was her own responsible party. She discharged from the facility on 05/12/26 to home. She had medical diagnoses including permanent atrial fibrillation (irregular heartbeat), muscle weakness, dysphagia (difficulty swallowing), unsteadiness on feet, abnormalities of gait and mobility, lack of coordination, cognitive communication deficit and need for personal care assistance. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 6 of 10 residents (Resident #40 and 5 unidentified residents on 100 hall) reviewed for infection control. RN H did not change contaminated gloves and wash her hands prior to exiting Resident #40's room and touched doorknob, nursing cart, and nursing computer when documented Resident #40's Accu-Check results. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.1. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to examine the results of the most recent survey of the facility conducted by Federal or State Surveyors and any plan of correction in effect with respect to the facility for 32 of 32 residents reviewed for the right to review survey results. The facility failed to post the results of the facility's most recent survey in a prominent and readily accessible place to residents, family members, legal representatives, and the public. This failure could place residents at risk of not being able to examine survey results without having to ask. During a group interview with six confidential residents on an undisclosed date at an undisclosed time, the residents revealed they did not know where the survey results were and available to read. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, were reported immediately to the administrator of the facility and to the State Survey Agency, for one Resident (Resident #1) of three residents reviewed for abuse/neglect. The facility failed to report to the administrator of the facility and to the State Agency that Resident #1's family on 02/04/25 had alleged that a CNA had pinched and been rough with Resident #1. This failure could place residents at risk for continuation or repetition of abuse, or abuse becoming more widespread.

Inspectors wroteBased on interview and record review, in response to an allegation of abuse, the facility failed to have evidence that all alleged violations were thoroughly investigated, and to prevent further potential abuse while the investigation was in progress for one (Resident #1) of three residents reviewed for abuse. The facility failed to thoroughly investigate an allegation that a staff member had been rough with and pinched Resident #1 and failed to suspend the alleged perpetrator on 02/04/25. This failure could place resident's at risk for continued abuse, unidentified injuries or trauma, and the spread of abuse to other residents.

Inspectors wroteBased on observation, interview. and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 (MA A) of 9 employees reviewed for abuse and neglect. The facility did not ensure MA A was disqualified from working in the facility when her criminal history, searched on 04/18/24 indicated a criminal conviction (on 03/05/24) barring employment in a nursing facility. MA A worked in the facility from 04/24/24 through 07/12/24. This noncompliance was identified as PNC. The deficient practice began on 04/24/24 and ended on 07/12/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for possible abuse, neglect, or exploitation.

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 3 (Server A, Server B and Dietary Manager) of 3 staff members reviewed in that: The facility failed to ensure Server A, Server B and the Dietary Manager performed hand hygiene when serving residents during lunch service. This failure placed residents at an increased risk of exposure to infections to include COVID- 19, decreased quality of life or hospitalizations.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed. There were unsealed bags containing dairy products in the refrigerator. 3 of 3 steam table wells had a whitish yellow substance in them. There was a heavily dented large metal colander. There were containers of spices open to air. This failure could place residents at serious risk for complications from food contamination.

Inspectors wroteBased on interviews and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents, Resident #8, reviewed for care plans in that: -Resident #8's care plan was not revised quarterly. This failure could place residents in the facility at risk of not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to accommodate residents' food preferences for 2 of 8 residents (Resident #3 and #16) reviewed for food preferences. 1. The facility failed to honor Resident #3's preferences for no condiments. 2. The facility failed to honor Resident #16's preference for her dislike of mustard. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.