Matlock Place Health & Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents and assistance devices to prevent accidents for 1 (Residents #109) of 10 residents reviewed for accidents and hazards. The facility failed on 6/28/26 to ensure Resident #109 was provided with appropriate assistance during incontinent care resulting in Resident #109 falling off the bed, receiving a laceration to his head, which required staples. On 7/07/26 at 7:10 p.m. an Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. The Administrator was provided with the IJ template, and a Plan of Removal (POR) was requested at that time. This failure could place residents at risk for falls, injuries, hospitalization, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 direct-care staff (CNA K) and 1of 1 resident (Resident #109) reviewed for proficiency of nurse aides. The facility failed to ensure CNA K was trained on fall protocol. On 6/28/26, CNA K performed incontinent care independently on Resident #109, which required a 2-person assist, that resulted in Resident #109 falling off the bed and sustaining a laceration to his head. The facility failed to ensure CNA K was granted access to the electronic system which contained resident care instructions. On 7/07/26 at 7:10 p.m. and Immediate Jeopardy (IJ) was identified. The Administrator and DON were notified. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for six residents (Resident #8, Resident #38, Resident #40, Resident #46, Resident #65, Resident #100) of 10 residents reviewed for ADL care. The facility failed to ensure Resident #46, had his fingernails trimmed on his left hand on 07/07/2026. The facility failed to ensure Resident #8 had her fingernails trimmed on 07/07/26. The facility failed to ensure Resident #38, Resident #40, Resident #65, and Resident #100 had their fingernails cleaned and trimmed on 07/07/2026. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and skin breakdown, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, and administering of medications for 3 (Nurses' Medication cart 100/300/400 Halls, Nurses' Medication cart 500 Hall, MAs' medication cart 100/300 Halls ) of 5 medication carts reviewed for pharmacy services. The facility failed to ensure prompt identification of potential diversion of controlled medications when RN F, RN E, and MA G did not report a damaged blister packs of Lorazepam 0.5 mg (controlled medication), Acetaminophen-Codeine 300-30 mg (controlled medication), and Alprazolam 0.5 mg (controlled medication). This failure could place residents at risk of not having their medication available due to possible drug diversion and at risk of not receiving the intended therapeutic benefit of the medication.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store food in accordance with professional standards for the facility's only kitchen observed for food service safety. The facility failed to:Ensure food items in the facility refrigerators and dry storage were dated and labeled on 07/07/2026. Ensure food items were labeled, dated, and stored in separate boxes in the freezer on 07/07/2026. Ensure expired food items stored in the dry storage area were discarded on 07/07/2026. These failures could place residents at risk for food borne illnesses and food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that was not possible or the resident preferences indicated otherwise for 1 of 5 residents (Resident #7) reviewed for nutrition status maintenance. 1. The facility failed to ensure Resident #7 had 2 CAL (Med Pass) three times a day leaving her with 105 missed doses. 2. The facility failed to measure and record Resident #7's body weight, as ordered by the resident's physician, for four weeks from 06/17/26 until 07/01/26. These failures could place residents at risk of weight loss, nutritional deficit, and adverse health consequences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #21) of one resident reviewed for pain management. The facility failed to ensure Resident #21 received pain assessments on every shift. This failure could place residents at risk of experiencing significant pain and, discomfort.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 3 residents (Resident #65) reviewed for dialysis. The facility failed to ensure Resident #65 had physician orders for his dialysis treatments. This failure could place residents at risk of missed dialysis appointments and decline in quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 5 residents (Residents #22 and #53) observed for infection control. 1. CAN B failed to wear appropriate PPE and perform hand hygiene while providing incontinence care to Resident #53 who was on EBP for open wound on 07/08/26. 2. The facility failed to ensure LVN D (Wound Care Nurse) wear appropriate PPE and performed hand hygiene during the wound care for Resident#22 who was on EBP for open wound on 07/08/26. This failure could affect the residents, by placing them at risk for worsening conditions and cross-contamination.

Inspectors wroteBased on observation and interview, the facility failed to right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 2 of 6 residents (Resident#1, and Resident#2) reviewed for accommodation of needs. The facility failed to ensure the call light system was within reach of the Resident #1 and Resident #2 on 06/30/2026. This failure could place residents in the facility at risk of being unable to obtain timely assistance form staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse of residents are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury to HHSC for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to report, within 2 hours, to the SA after Resident #1 alleged sexual abuse to her Mental Health Habilitator on [DATE], who then notified the facility the same day on [DATE]. The facility did not report Resident #1's allegation to law enforcement, nor the SA. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the status for 3 of 5 residents (Residents #3, #4, and #22) reviewed for accuracy of assessments in that: The facility staff failed to address Resident #22, Resident #3, Resident #4, and Resident#5's respiratory treatments on the MDS.These failures could place residents at risk of not receiving care and treatments.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being, for 5 of 5 residents (Residents #10, #22, #3, #4, #5 and #10) reviewed for care plans, in that: Resident #10, #22, Resident #3, Resident #4 and Resident #5's care plan did not address the respiratory treatments. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 5 (Residents #10, Resident #22, Resident #3, Resident #4, and Resident #5) of 10 residents reviewed for respiratory care, in that:. Resident #10, Resident #22, Resident #3, and Resident #4's nebulizer mask was not bagged. Resident #4's and Resident #5's NC tubing was not dated. These failures could place residents at risk of receiving inadequate respiratory careFindings: Resident #10 Record Review of Resident #10's face sheet dated 11/23/2025, reflected the resident was a 78 years-old female that was admitted on [DATE]. The resident was diagnosed with: [...]

Inspectors wroteBased on observations, interviews, 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 of 3 Residents (Resident #1 Resident #2 and Resident #3) observed for infection control. 1. The facility failed to ensure CNA F utilized Enhanced Barrier Precautions, performed hand hygiene during incontinence for Resident #1 and performed hand hygiene prior to leaving Resident #1 room on 11/23/25. 2. The facility failed to ensure CNA E utilized Enhanced Barrier Precautions, performed hand hygiene during incontinence care and mechanical lift transfer to Resident #2 and performed hand hygiene prior to leaving Resident #2's room on 11/23/25. 3. [...]

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing, prevent infection, and prevent new ulcers from developing for one of six residents (Resident #3) reviewed for pressure ulcers The facility failed to ensure LVN A provided Resident #3 her physician ordered wound care on 11/22/25. This failure could place residents at risk of developing infections or worsening of their wounds.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of six residents (Resident #1) reviewed for accidents hazards The Facility failed to ensure CNA F provided a safe two-person transfer and instead lifted Resident #1 under her arms when transferring her from her bed to her wheelchair on 11/23/25. These failures could affect the residents by placing the residents at risk for falls, injuries, and skin tears.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for two of six residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to ensure Resident #2, who had prior behaviors towards others, did not physically abuse Resident #1. On 08/26/25, Resident #2 had her hands around Resident #1's neck and had to be separated by facility staff. An Immediate Jeopardy (IJ) situation was identified on 08/27/25. While the IJ was removed on 08/28/25, the facility remained out of compliance at a scope of pattern with a potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs that are identified in the comprehensive assessment that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #2) reviewed for care plan accuracy. The facility failed to develop and implement a care plan revised on 08/14/25 for Resident #2, which addressed her physically aggressive behaviors towards others between 08/02/25 to 08/26/25. LVN A and CNA E were able to pull Resident #2's hand away from Resident #1's neck on 08/26/2025. An IJ was identified on 08/27/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (is a medication used: without adequate indication for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued) for one of five residents (Resident #2) reviewed for unnecessary medications. The facility failed when ADON J did not ensure Resident #2, who had a diagnosis of Alzheimer's disease (dementia), was not prescribed an antipsychotic medication, Seroquel, without a diagnosis for the use of the antipsychotic and that was not approved for treatment of patients with dementia-related psychosis. The Psych NP said he had ordered the Seroquel for Resident #2's unspecified psychosis which he diagnosed her with after meeting Resident #2 a few times. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plans 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 5 (Residents #85 and #58) reviewed for comprehensive care plans. 1. The facility failed to develop a care plan for Resident #85's hospice services. 2. The facility failed to develop a care plan for Resident #58's enteral feeding. These failures placed resident at risk of not receiving appropriate care.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 (Residents #16, #35, and #198) of 3 residents reviewed for pressure ulcers. 1. On 05/19/25, the facility failed to provide PRN wound care to Resident #16's right buttocks wound. 2. On 05/17/25 and 05/18/25, the facility failed to provide wound care to Resident #35's left foot. 3. On 05/09/25, the facility failed to provide wound care to Resident #198's sacrum wound. These failures placed residents at risk of developing new or worsening pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means, received the appropriate treatment and services to prevent complications of enteral feeding, for 2 of 4 resident (Residents #16 and #58) reviewed for enteral nutrition. 1. The facility failed to follow physician orders for Resident 16's enteral feeding tube formula when it was not available and required a substitution. 2. The facility failed to follow Resident #58's physician orders for enteral feeding by not allowing Resident to have down time between the hours of 8:00 AM-12:00 PM. These failures could place residents who had gastrostomy tube at risk for weight loss, weight gain or stomach and digestion issues.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #23 and #33) reviewed for dialysis. 1. The facility failed to ensure dialysis communication forms were completed for Resident #23 after returning from dialysis treatment. 2. The facility failed to ensure Resident #33 had an order to complete dialysis treatment. This failure could place residents at risk of inadequate monitoring after returning to facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts (600,700 and 800 Halls cart) and 3 of 3 residents (Residents #68,#91 and #98) reviewed for pharmacy services. The facility failed to ensure the 600,700 and 800 Halls nurses' medication cart had accurate narcotic counts for Residents #68, #91 and #98. This failure could place residents at risk for medication errors, drug diversion, and delay in medication administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for 1 of 3 staff (LVN B) which resulted in a 43.9 % medication error rate after 41 opportunities with 18 errors for 1 of 4 residents (Resident #16) reviewed medication administration. LVN B failed to follow the physician orders for flushing Resident #16's gastrostomy tube with 5-10 mL (or prescribed amount) of water between medications, when she administered 13 medications to Resident #16. LVN B also failed to administer all the medications in medicatoin cups leading to 5 cups being left with residual medication. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure the menus were followed for 1 (the lunch meal on 05/20/25) of 2 meals reviewed for menus. The facility did not serve the correct portions of pureed broccoli and cauliflower, pureed pizza pasta bake, and pureed garlic bread for the lunch meal on 05/20/25. This failure could affect residents in the facility, who eat from the kitchen, by placing them at risk of being hungry or losing weight.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility provided food that was palatable, for one (the lunch meal on 05/20/25) of three observed meals reviewed for dietary services. The facility failed to serve food that had a smooth, pudding like texture during the lunch meal on 05/20/25. This failure could affect residents by placing them at risk of weight loss, altered nutritional status, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 20 residents (Resident #36) reviewed for clinical records. The facility failed to have complete records for Resident #36's wound care for April and May 2025 This failure could place residents at risk for incomplete and inaccurately documented medical records that included their progress treatment, services, and interventions.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 2 residents (Residents #2 and #16) observed for infection control. 1. CNA P and C N A Q failed to perform hand hygiene while providing incontinence care to Resident #16. 2. The facility failed to ensure Wound Care Nurse performed hand hygiene and change gloves during the wound care for Residents #2 and #16. This failure could affect the residents, by placing them at risk for worsening conditions and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and home-like environment for 1 of 5 residents (Resident #73) reviewed for environment. The facility failed to ensure Resident #73 had a home-like environment when she was relocated temporarily to another room leaving her without any of her belongings or entertainment. These failures could place residents at risk of an uncomfortable environment, depression and feeling lonely.

Inspectors wroteBased on interview and record review, the facility failed to ensure nurse aides received required training which included dementia management training for 1 of 16 (CNA V) staff reviewed for in-service training requirements. The facility failed to ensure CNA V received dementia management training. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of disease and infection for 7 of 7 rooms (Rooms #605, #607, #608, #703, #704, #801, and #805) reviewed for infection control. The facility failed to ensure that staff had appropriate Personal Protective Equipment (PPE) readily available to wear when entering rooms (Rooms #605, #607, #608, #703, #704, #801, and #805) on droplet precautions to prevent the spread of infection. This failure placed all residents, as well as employees and visitors, at risk of communicable diseases.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one of five residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1's medications were correctly documented on his quarterly and annual MDS assessments. This failure could place residents at risk of inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when CNA B transferred her roughly from bed to a geri-chair and then slapped her hand when she attempted to hold onto the bed on 08/31/24. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/31/24 and ended on 09/03/24. The facility had corrected the noncompliance before the investigation began. This failure placed residents at risk of abuse, trauma, and psychosocial harm.

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 of 4 residents (Resident #1) reviewed for accidents and supervision. CNA B failed to use a gait-belt to transfer Resident #1 from the bed to a geri-chair on 08/31/24 resulting in rough care during the transfer. The noncompliance was identified as past noncompliance. The Immediate Jeopardy began on 08/31/24 and ended on 09/03/24. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk for neglect, harm, pain, and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 5 residents (Residents #1 and #2) reviewed for ADL care. The facility failed to provide Residents #1 and #2 assistance with timely incontinence care on 10/31/24. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately notify the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for physician notification of changes. 1. The facility failed to consult with Resident #1's physician and provide all necessary details, when MA A failed to inform LVN A that Resident #1 refused to take her Lactulose medication on Saturday, 10/05/2024 (12:00 PM) and again on Sunday, 10/06/2024 (12:00 PM and 5:00 PM) for a total of 3 doses. 2. The facility failed to follow their policy on medication administration on 10/05/2024 and 10/06/2024 by MA A not immediately detailing any refusals by Resident #1 of her Lactulose medication to LVN A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 1 residents (Resident #1) reviewed for accidents. On 04/04/24, Resident #1 sustained a right shoulder fracture when CNA B left him unattended in his room while he was sitting in a shower chair. The noncompliance was identified as PNC. The noncompliance began on 04/04/24 and ended on 04/04/24. The facility has corrected the noncompliance before the survey began. This failure could place residents at risk for serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food, subject to spoilage and removed from its original container, was kept sealed, labeled, and dated in the facility's only kitchen. 1. The facility failed to ensure food items stored in the freezer were properly labeled with the contents after being removed from the original packages and not dated to reflect when the food items were opened. 2. The facility failed to ensure the freezer was maintained in a sanitary manner free from dark substances. This failure could place all residents at risk for food contamination and food borne illness.

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 for 2 (Residents #21 and #54) of 5 residents reviewed for quality of care. 1. The facility failed to follow physician orders for weekly weights on Resident #21 resulting in a weight gain. 2. The facility failed to obtained physician orders for Resident #54 use of hinged knee brace. This failure could place the resident at risk of not receiving the care intended by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the system for identifying and reporting infections and communicable diseases for all resident was followed for 1 (Resident #63) of 2 residents reviewed for infection control. The staff failed to notify the physician of Resident #63's urine culture being positive for an infectious agent, resulting in a delay in starting antibiotics and contact isolation. This failure could place residents at risk of being exposed to an infectious agent.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to ensure the facility was free of pests for 3 (100, 200 and 400 Hall) of 6 Halls, and 1 of 1 conference room reviewed for pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of gnats throughout the facility. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent neglect for one (09/12/23) of one incidents reviewed for reporting. The facility failed to follow their policy to report to the State Survey Agency when Resident #302 tilted in her wheelchair while being transported to an appointment in the facility van. This failure could place the residents in the facility at risk of lacking timely reporting of incidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported immediately but not later than 24 hours if the events that cause the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency for one of one incidents reviewed for reporting. The facility failed to report to the State Survey Agency when Resident #302 tilted in her wheelchair while being transported to an appointment in the facility van. This failure could affect residents by resulting in a delay of identification of abuse or neglect and lack of timely follow-up on recommended interventions to prevent harm, or impairment.

Inspectors wroteBased on interview and record review, the facility admitted a resident with a mental disorder before the State mental health authority had determined he was appropriately placed for 1 of 7 residents (Resident #95) reviewed for Preadmission Screening and Resident Review (PASARR) screening. The MDS Coordinator failed to complete the PASARR screening process accurately for Resident #95. This failure could place residents at risk of not receiving specialized services.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop a comprehensive care plan for 1 (Resident #54) of 5 residents reviewed for comprehensive care plans. The facility failed to update Resident #54's care plan to address the use of his hinged knee brace. This failure could result in the resident not receiving appropriate care for his fracture.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents who were unable to carry out activities of daily living the necessary services to maintain grooming and personal hygiene for two (Residents #35 and #83) of eight residents reviewed for facial hair. The facility failed to remove Resident #35 and Resident #83's facial hair. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for two (Resident #40 and #302) of six residents reviewed for accidents. 1. The Van Driver failed to properly restrain Resident #302's wheelchair in the facility transportation van to prevent the wheelchair from tipping over on its side on the way to dialysis on 09/12/23. 2. The facility failed to provide adequate supervision for Resident #40 when she was stuck outside in the courtyard and she was not able to call the facility because their phone lines were down. This failure could place residents at risk for serious injury or harm, decline in health, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was fed by enteral means received appropriate treatment and services to prevent complications for one (Resident #46) of four residents reviewed for feeding tubes. The nursing staff failed to ensure Resident #46's water flushes were correct on the feeding pump per the physician orders. The failure placed residents, who received nutrition via g-tube, at risk for decreased nutritional intake and weight loss complications.

Inspectors wroteBased on record review and interviews the facility failed to provide or obtain laboratory services to meet the needs of its residents in a timely manor for 1 (Resident #77) of 5 residents reviewed for laboratory services in that The facility failed to follow physician orders for routine lab work for Resident #77, resulting in the lab not being performed. This failure could result in missing resident's medical conditions getting worse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared by methods, which conserved nutritive value, flavor, and appearance for one of one pureed meal observed for nutrition. The Dietary Manager failed to ensure the pureed lunch meal on 03/24/24 was prepared according to the recipe to conserved nutritive value and flavor. The failure could place residents, who were on a pureed diet, at risk for a decrease in nutritive status, loss of appetite, decreased intake and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily nurse staffing was posted as required each day for three (03/24/24, 03/25/24 and 03/26/34) of three days reviewed for nursing services and postings. The facility failed to update the daily staffing information posting on 03/24/24, 03/25/24 and 03/26/24. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #6) of five residents reviewed for radiology services. The facility failed to properly enter a request for an x-ray on 01/27/24 after Resident #6's spouse report swelling at the right hip and that he had pain when he was being changed or repositioned. This failure placed residents at risk of a delay in medical evaluation and treatment, pain, and a decrease in quality of care.

Inspectors wroteBased on observation, interview and record review, the facility failed to promptly notify the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for one (Resident #6) of five residents reviewed for radiology services. The facility failed to retrieve results of an x-ray order of Resident #6's right hip in a timely manner. This failure placed residents at risk of a delay in medical evaluation and treatment, pain, and a decrease in quality of care.

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 of 4 (ADON B, CNA C, Medical Records and Dietary Supervisor) of 6 staff members reviewed for infection control practices. The facility failed to ensure ADON B, CNA C, Medical Records and Dietary Supervisor donned proper PPE prior to entering the COVID Unit. This failure could place residents at risk of cross-contamination and infections such as COVID-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 4 residents (Resident #1) reviewed for pressure ulcers. The facility failed to ensure the pressure ulcer on Resident #1's sacrum (a triangular bone in the lower back formed from fused vertebrae and situated between the two hipbones of the pelvis) was covered with a dressing as ordered, and failed to ensure the dressings on both heels and on the right hip were dated. This failure could affect the residents, who received pressure ulcer care, by placing them at risk for contamination of their wounds and causing unnecessary infections and worsening of pressure ulcers.