Maverick Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 2 of 2 Residents (Resident #1 and Resident #2) reviewed for resident rights. CNA E failed to sit down while feeding Resident #1 and Resident #2 during the dinner meal on 6/25/26. This deficient practice could place residents at risk to feelings of poor self-esteem.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental or psychosocial status (that was, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 5 Residents (Resident #5) reviewed for notification of changes. RN F failed to consult with Resident #5's physician when she administered two 100 mg tablets instead of two 50 mg tablets of Senna-Docusate. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 3 of 26 resident rooms (room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) in that: The facility failed to ensure the vents were cleaned and rid of excess lent in Resident rooms #203, #213 and #215. This deficient practice could place residents at risk of being in an uncomfortable and unsanitary environment.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had a right to and the facility provided prompt efforts to resolve grievances the resident may have for 1 of 5 Residents (Resident #3) reviewed for grievances. The facility failed to promptly act upon concerns a family member voiced to the ADM and DON on Resident #3's behalf involving her care during her stay in the secured unit. This deficient practice could place residents at risk of not being made aware of any corrective actions taken by the facility leading to frustration.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 4 Residents (Resident #1) reviewed for ADL's. Nursing staff failed to change Resident #1's shirt which was covered with skin flakes all over his chest area. This deficient practice could place residents at risk to feelings of dissatisfaction or poor self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 4 (Resident #4) reviewed for accidents and hazards. Nursing staff failed to ensure they cleaned up a puddle of water on the floor underneath Resident #4's chair during dinner time. This deficient practice could place residents at risk and of avoidable accidents.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administrating of all drugs and biologicals) to meet the needs of each resident for 1 of 5 Residents (Resident #5) reviewed for pharmacy services. RN F failed to administer the correct milligrams of Senna-Docusate to Resident #5. This deficient practice could place residents at risk of diarrhea and dehydration.

Inspectors wroteBased on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 1 of 5 Residents (Resident #5) reviewed for complete and accurate records. Nursing staff failed to complete a medication error report when RN F administered two 100 mg. versus two 50 mg tablets of Senna-Docusate to Resident #5 and failed to complete an SBAR when she was unable to successfully inject an IV into the back of Resident #5's right hand for the administration of Vancomycin (anti-biotic therapy) for the diagnosis of MRSA. ADON D failed to document a progress note reflecting he notified Resident #5 when an allergy medication was changed from scheduled to PRN administration. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 dining room in that: The facility failed to ensure the vents were cleaned and rid of excess lent in the dining room in the secured unit. This deficient practice could place residents at risk for feeling uncomfortable and lead to cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to provide food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen observed. 1. The facility failed to maintain the temperature for puree bread at 135 F or above. These failures could place residents at risk for weight loss, poor quality of life and food borne illness.

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 food storage safety. 1. The kitchen had an unsealed cheese bag dated 12/4/2025 in the fridge,2. The kitchen had an unsealed cilantro bag dated 12/5/2025 in the fridge.3. The kitchen had an unsealed pizza dough bag dated 10/26/2025 in the freezer.4. The kitchen had an undated macaroni container in the pantry5. The kitchen had a tomato that appeared to be spoiled in the fridge. This deficient practice could place residents who eat food from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents had the 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 1 of 7 residents (Resident # 1 ) reviewed for call light. The facility failed to ensure Resident # 1's call light was within reach. This failure could place residents at risk of not achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on interviews, and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 2 residents (Resident #68) reviewed for PASARR accuracy.1. The MDS Case Manager did not refer Resident #68 for a level II resident review upon newly evident serious mental health disorder. This deficient practice could place the residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observations, 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 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 (Resident # 83) of 24 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #83's care plan included Contact Isolation which was ordered to prevent spread of her infection C-diff and EBP for her infected wound which required treatment and a dressing. Resident #83's comprehensive person-centered care plan did not reflect the use of PPE as an intervention. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 resident (Resident #30) of 3 residents reviewed for oxygen therapy. Resident #30's oxygen concentrator left side black foam filter was gray from being covered with air particles and dust. This deficient practice affects residents who receive oxygen therapy and could result in hypoxia (low oxygen) and difficulty breathing.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 (refrigerators in resident room [ROOM NUMBER]-B) of 5 residents' refrigerators reviewed in that: The personal refrigerator in resident's room [ROOM NUMBER] B contained unlabeled, undated food items. This deficient practice could place residents at risk of foodborne illness due to consuming foods which could be spoiled.

Inspectors wroteBased on observations, interviews and record reviews, 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 2 residents (Resident #36 and #83) who were reviewed for infection control.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access, for 1 of 6 medication carts (300-hall medication cart), reviewed for security. LVN B left the 300-hall medication cart unattended and unlocked. This failure could place residents at risk for having their medications uncontrolled.

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, for 1 of 1 residents pantry refrigerators reviewed for food safety. The facility stored resident's foods in the Resident's pantry refrigerator without labels and dates to indicate if the foods were safe to serve. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #54) reviewed for quality of care. The facility failed to ensure Resident #54 was properly secured in the facility transport van on 08/22/24 and sustained a fall resulting in fractures to the third and fourth left hand fingers and a fracture to the right elbow. The noncompliance was identified as PNC. The IJ began on 08/22/204 and ended on 08/24/2024. The facility had corrected the noncompliance before the survey began. Assessment of Resident #54. Inservice training to all staff related to Abuse and Neglect and Reporting Incidents to MD and RP. Van safety training with 7 van drivers to include proper use of van lift and proper ways to secure residents in wheelchairs. [...]

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 1 of 1 kitchen, in that: The facility failed to ensure three packets of bread, observed in the freezer on 09/08/2024, were labeled and dated, and that one of packets was not opened in the freezer because the plastic bag was torn. This failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

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 disease and infection for 2 of 6 residents (Residents #83 and #63) reviewed for infection control, in that: 1. The facility failed to ensure CNA AD used the proper technique to sanitize her hands while providing incontinent care for Resident #83. 2. The facility failed to ensure CNA-AD and CNA-AE wore a gown while performing incontinent care for Resident #63 who was on EBP (Enhanced Barrier Precautions) on 09/10/2024. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #17) reviewed for resident rights, in that: The facility failed to ensure CNA AD and CNA AE completely closed Resident #17's privacy curtain while providing incontinent care. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 18 residents (Residents #40 and #9) whose assessments were reviewed, in that: 1. The facility failed to ensure Resident #40's quarterly MDS, dated [DATE], correctly documented the resident as receiving an anticoagulant medication. 2. The facility failed to ensure Resident #9's, who was a smoker, annual MDS, dated [DATE], did not reflect the resident did not use tobacco. These failures could place residents at-risk for inadequate care and services.

Inspectors wroteBased on interviews and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder for level II resident review for 1 (Resident #68) of 18 residents reviewed for resident assessments. The facility failed to refer Resident #68 for re-evaluation of PASARR level I review following a diagnosis of schizoaffective disorder-bipolar type, added on 01/05/2024. This failure could place residents at risk of not having their mental health needs met by the facility and could place all residents at risk of harm by mentally unstable residents. Findings Included: Record review of Resident #68's face sheet, dated 09/10/2024, revealed the resident was [AGE] years old male and an admission date of 11/08/2021 with diagnoses that included: [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 18 residents (Resident #17) reviewed for comprehensive care plans, in that: The facility failed to ensure Resident #17, who was always incontinent of bladder and bowel, had a care plan regarding bowel incontinence care. This deficient practice could place residents at risk for not receiving proper care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #79) of 3 residents reviewed for quality of care. The facility failed to ensure Resident #79, who was receiving Glucerna at a rate of 55 ml/hour via tube feeding on 09/08/2024, coincided with the physician order that indicated providing Glucerna at a rate of 60 ml/hour to the resident. This failure could place residents at risk of not receiving the proper tube feeding requirements prescribed by the physician.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 of 2 residents (Residents #63) reviewed for quality of care in that: The facility failed to ensure Resident #63's nebulizing mask and tubing, that were observed on 09/08/2024, were not covered in a plastic bag dated on 07/21/2024. This failure could affect residents who received nebulizing treatment and place them at risk for respiratory infections.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 6 residents (Resident #6) reviewed for advanced directives in that: Resident #6 did not have advance directives documented in the admission agreement or electronic medical record from the date of admission, [DATE], to discharge date , [DATE]. This deficient practice could affect residents admit to the facility and place them at risk of not having their wishes known, which could delay emergency treatment.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, on 5 days during the look back period from April 1, 2023, to August 8, 2023 (99 calendar days). The facility failed to maintain RN coverage on: April 1,2023, April 2, 2023, April 5, 2023, May 12, 2023, and May 13, 2023. This failure could affect all 82 residents of the facility by placing them at risk for not having their nursing and medical needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure that its activities program was directed by a qualified professional. The Activity Director was not currently qualified to direct the activities program. This failure could result in not meeting the assessed activity needs of each resident.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #44) reviewed for dialysis in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #44. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure Residents have the right to formulate an advance directive for 1 of 9 resident (Resident # 73) reviewed for advanced directive in that: The facility failed to have the physician's signature recorded on the Out of Hospital Do Not Resuscitate (OOHDNR), which made the advanced directive invalid. This deficient practice could place residents at risk of not having their wishes known, which could affect whether they receive emergency medical treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 or 2 residents (#73). Resident #73's oxygens was administered at 2 Liters Per Minutes instead of 1 Liter Per Minute via nasal cannula as ordered by the physician. This deficient practice could affect 2 residents who received oxygen continuously and result in residents receiving incorrect or inadequate oxygen support and could result in decline in health.

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 2 of 18 residents (Resident #55 and #64) reviewed for infection control practices, in that: During the medication pass, LVN B: -placed clean gloves in her pocket -did not perform hand hygiene prior to care and between glove changes -did not sanitize the digital wrist blood pressure cuff between resident use These failures could place residents at risk for infection, transmission for communicable diseases and/or a decline in health.