Medina Valley Health & Rehabilitation Center

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 4 of 6 residents (Resident #3, Resident #4, Resident #41, and Resident #42) who were reviewed for resident assessments. 1. The facility failed to document Resident #4's use of anticonvulsant medication on the quarterly MDS assessment. 2. The facility failed to document Resident #41's use of diuretic medication on the annual MDS assessment.3. The facility failed to document Resident #3's admission to hospice services on the Significant Change Assessment.4. The facility failed to document Resident #42's hospice services on her last quarterly MDS assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

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 disease and infection for 2 of 16 residents (Resident #21 and Resident #91) reviewed for infection control: 1. The facility failed to ensure CNA D and CNA E wore a PPE gown during incontinent care for Resident #21 who was on EBP. 2. The facility failed to ensure CNA D did not touch a clean brief with dirty gloves during incontinent care for Resident #21. 3. The facility failed to ensure LVN F cleaned the rubber hub of an insulin pen prior to placing a needle cap on the pen and administering it to Resident #91. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident having pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for 1 of 4 resident (Residents #21) reviewed for quality of care. The facility failed to ensure on 2/25/26 LVN A cleansed Resident #21's entire wound bed, did not use wound vac canister tubing that was touching the floor, and sanitized the entire surface area of scissors used to cut wound supplies. These failures could result in the residents with pressure ulcers worsening in size and staging.

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, for 1 of 1 facility reviewed for nurse services. The facility failed to have RN coverage for 2 days on 9/01/2025 and 12/26/2025. This failure could place residents at risk of not having staff with advanced care skills available to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 8 residents (Residents #71) reviewed for administration. The facility failed to document an incident Resident #71 had with Resident #83 in her electronic medical record. This deficient practice could place residents at risk of delayed or improper care due to inaccurate medical records. Record review of Resident #71's admission record, dated 2/25/26, revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE] with diagnoses that included dementia, major depressive disorder, and generalized anxiety disorder. Record review of Resident #71's Quarterly MDS assessment, dated 12/31/25, revealed the resident's BIMS score was 13 (intact cognition). [...]

Inspectors wroteBased on observations and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one laundry room reviewed for physical environment. The 2 dryers were found to have built up lint on top of the lint screen. This deficient practice could place residents at risk for burns due to a fire hazard.

Inspectors wroteBased on interview and record review, the facility failed to assess each resident using the quarterly review instrument specified by the State and approved by CMS in a timely manner for 1 (Resident #42) of 8 residents reviewed for timely assessment, in that: The facility failed to complete Resident #42's quarterly MDS assessment by 2/6/26 This failure could lead to residents not receiving necessary, complete, or correct care due to lack of current information.

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 kitchen sanitation. 1. The facility failed to ensure that sanitizing buckets were not near containers of food. 2. The facility failed to discard expired flour. 3. The ice machine had an unknown black substance inside the top of the machine. 4. The dishwasher sanitation log was not completed for several days and had an expired bottle of test strips. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #15) of 8 residents reviewed for resident rights. The facility failed to notify Resident #15's provider of her change of condition on [DATE] when she developed dysuria (a painful or uncomfortable feeling when urinating, often described as a burning, stinging, or itching sensation in the urethra or urethral meatus) and visual hallucinations (Seeing things that aren't there, such as flashing lights, animals, or people). This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 7 Residents (Resident #36) whose records were reviewed for assessments. MDS staff failed to ensure Resident #36's MDS assessment reflected he was hearing impaired and used an amplifier as a hearing aid. This deficient practice could affect any resident and could result in residents not receiving the care and services as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure all PASRR Level I residents with mental illness were provided with a PASRR Level II Evaluation and Assessment for 1 of 2 residents (Resident #55) reviewed for PASRR services. The facility failed to identify Resident#55 as having diagnoses indicative of Mental Illness including MDD on the PASRR screening dated 3/10/23, which would require a PASRR Level II assessment. This deficient practice could place residents at risk of a diminished quality of life related to not receiving or benefiting from specialized services.

Inspectors wroteBased on interview and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 1 of 2 residents (Resident #52) whose records were reviewed for PASRR services. The facility failed to recognize on the Level I PASRR screening that Resident #52 had the mental illness diagnoses of Post Traumatic Stress Disorder (PTSD) and Major Depressive Disorder (MDD) which would qualify Resident #52 for a PASRR evaluation. This deficient practice could place residents with mental illness at risk for not obtaining the services needed to treat their mental health diagnoses.

Inspectors wroteBased on observations, interviews, and record review revealed the facility failed to ensure the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 2 of 7 Residents (Resident #36 and Resident #15) whose records were reviewed for Care Plans. 1. Staff failed to ensure Resident #36's Care Plan reflected he was hearing impaired and used an amplifier as a hearing aid. 2. The facility failed to update Resident #15's Care Plan to reflect a history of UTIs with interventions for staff to monitor the resident for possible UTI symptoms. This deficient practice could affect any resident and result in residents not receiving the care and services they needed. 1. [...]

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 the necessary services to maintain good personal and oral hygiene for 1 of 7 Residents (Resident #36) whose records were reviewed for activities of daily living. Nursing staff failed to brush Resident #36's teeth and wash his face for 1 of 4 survey dates, 11/14/24 and nursing staff failed to clip his nails for an undetermined amount of time. This deficient practice could affect residents who required assistance and could result in poor hygiene and feelings of dissatisfaction.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #191 and Resident #15) of 2 residents reviewed for catheter care and or incontinent care. 1. The facility failed to ensure CNA L and CNA M did not leave stool on Resident #15 when performing incontinent care. 2. The facility failed to ensure CNA J and CNA K kept Resident #191's urine catheter bag below the level of the bladder during incontinent care. This failure could place residents at risk for urinary tract infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for two of ten residents (Resident #24 and Resident #41) reviewed for pharmacy services. The facility failed to ensure medication doses noted on the electronic Medication Administration Record (MAR) matched doses recorded on the Controlled Drug Reconciliation Log for Resident #24 and #41. This deficient practice could put residents at risk for pain, anxiety, misappropriation, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all medications were labeled in accordance with currently accepted professional principles for one of ten residents (Resident #55) reviewed for medication labeling and storage. The facility failed to ensure Resident #55's insulin pen was labeled with the date it was opened. This deficient practice could place residents who receive medications at risk of not obtaining the therapeutic level of their prescribed medications.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #15 and Resident #191) of 8 residents reviewed for accuracy and completeness of clinical records. 1. The facility failed to timely document Resident #15's complaints of dysuria (a painful or uncomfortable feeling when urinating, often described as a burning, stinging, or itching sensation in the urethra or urethral meatus) on 11/03/24 and 11/11/24. 2. The facility failed to document a wound care order in active orders, when it was ordered on 11/12/24, and not active until 11/14/24, for wound care treatment for Resident #191 who developed a open reddened area to her gluteal folds after admission. [...]

Inspectors wroteBased on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 residents (Resident #191) reviewed for hospice services, in that: The facility failed to ensure Resident #191's most recent Physician Certification of Terminal Illness and Hospice Election form were completed and were part of the hospice documents at the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

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 1 of 4 residents (Residents #15) reviewed for infection control 1. The facility failed to ensure CNA L and CNA M used appropriate hand hygiene between glove changes when providing incontinent care to Resident #15. 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 maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 multi compartment sinks (Dishwashing Sink) reviewed for essential equipment. The facility did not ensure the dishwashing sink was not leaking and used a food safe repair sealant. This failure could place the residents at risk of foodborne illness for consuming food washed in potentially contaminated water.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 2 of 2 Dumpsters (Dumpster #1 and Dumpster #2) reviewed for disposal of garbage. The facility failed to ensure the waste in Dumpster #1 and Dumpster #2 was not leaking and staining the ground around the dumpsters. These deficient practices could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures, for 2 of 8 residents (Residents #1 and #2) reviewed for reporting allegations of abuse and neglect. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 8 (Resident #1) residents reviewed for 2 person staff assistance with mechanical lift transfers. CNA C transferred Resident #1 by herself, with a mechanical lift, and caused Resident #1 transient head pain. Resident #1 was assessed as needing more than 1 staff assistance with all transfers. The non-compliance was identified as past non-compliance. The noncompliance began on 12/8/23 and ended on 12/11/23. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for harm by neglecting to provide more than 1 staff assistance with mechanical lift transfers.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 8 residents (Resident #3) reviewed for catheter care. The facility failed to ensure LVN A used a sterile technique when flushing Resident #3's urinary catheter. This failure could place residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (Medication cart #1) reviewed for medication storage. The facility failed to ensure the Medication cart in the public area was locked. This failure could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or serious bodily injury for 1 (Resident #1) of 4 residents reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report an allegation of resident neglect regarding Resident #1's unwitnessed fall with major injury to the State Agency within the allotted time frame of 2 hours. This failure could place all residents at increased risk for potential neglect due to unreported allegations of neglect.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to protect resident's clinical records for 2 of 6 residents (Residents #1 & #5) reviewed for clinical records, in that: MA A failed to lock and disable access to Resident #1's electronic health record while he walked away from his medication cart. LVN B failed to lock and disable access to Resident #5's electronic health record while she walked away from her medication cart. This failure could affect residents by having their records viewed and accessed by unauthorized personnel and violate the HIPAA.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for 3 of 3 residents (Resident #61, #82 and #40) observed for physical restraints in that: 1. The facility failed to obtain a consent for Resident #61 to wear a wander guard. 2. The facility failed to obtain a consent for Resident #82 to wear a wander guard. 3. The facility failed to obtain a consent for Resident #40 to wear a wander guard. This failure placed residents at risk of unnecessary restriction of their freedom of movement and diminished quality of life.

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: 1. The facility failed to ensure proper dating was used on dry and refrigerated items. 2. The facility failed to ensure dry food was stored in a proper container. 3. The facility failed to ensure there was paper towels at the hand washing sink. 4. The facility failed to ensure raw meat was thawed properly. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne 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 2 of 3 residents (Resident #76 and #43) reviewed for infection control practices, in that: 1. CNA C and RN D did not utilize appropriate hand hygiene during incontinent/peri care to Resident #76 2. LVN A placed a medication into the palm of her ungloved hand intended for Resident #43 These failures could place residents at risk of infection or a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and restore continence to the extent possible, for 1 of 2 Residents (Resident #76) reviewed for perineal/incontinent care, in that: CNA C failed to clean between Resident #76's vaginal folds during incontinent/peri care This deficient practice could place residents at risk of increased urinary tract infections due to improper care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, and described in the plan of care for 4 of 7 residents (Resident #19, #80, #24, and #20) reviewed for nursing competencies, in that: LVN A failed to administer 7 medications outside of acceptable parameters for safe medication administration for Residents #19, #80, #24 and #20 and stored 2 medication cups with loose pills inside the medication cart. This failure could place residents at risk for not receiving their medications, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 32% based on 8 out of 25 opportunities, which involved 5 of 7 Residents (Residents #43, #19, #80, #24, and #20) reviewed for medication administration, in that: LVN A allowed Resident #43 to self-administer his inhaler without a physician's order or assessment and failed to administer 7 medications outside of acceptable parameters for safe medication administration for Residents #19, #80, #24 and #20. This failure could place residents at risk for not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents are free of any significant medication errors for 2 of 7 residents (Resident #19 and #24) observed during medication administration in that: LVN A failed to administer Resident #19's insulin and Resident #24's insulin and seizure medication as prescribed by the physician. These deficient practices placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly, for 1 of 2 dumpsters in that: Dumpster #1 had the side door open with garbage items visible and garbage on the ground outside the dumpster. This deficient practice could place residents who reside at the facility at risk of unsanitary conditions that could result in the attraction of vermin and rodents and expose them to germs and diseases carried by vermin and rodents.