Mineral Wells Nursing & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described 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 18 residents (Resident #9) reviewed for comprehensive care plans, in that: 1. Resident #9's comprehensive care plan did not address Resident #9's urinary catheter needs and associated risk factors. The failure placed the resident at risk for not receiving the care and services needed to meet the resident's needs and a decline in health status.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who was incontinent of urine and had an indwelling urinary catheter had a clinical condition demonstrating the catheterization was necessary for 1 of 4 residents (Resident #9) reviewed for urinary catheters, in that:Resident #9's order summary did not include an order that specified the type and size of urinary catheter and the clinical indication for use of the catheter. The failure placed the resident at risk for not receiving the care and services needed to manage the resident's urinary incontinence and avoid the development of urinary tract infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure the temperature of the banana pudding was taken prior to leaving the kitchen. The facility failed to ensure that staff performed hand hygiene while preparing food. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide services with reasonable accommodation of needs for 1 of 10 (Resident #9) residents reviewed forreasonable accommodation of needs The facility failed to provide a working communication system on 04/15/2025 that was easily at reach and that would allow Resident #9 the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure at the time each resident was admitted , the facility had a physician order for the resident's immediate care for 1 (Resident #47) of 32 residents reviewed for residents receiving necessary care and services upon admission. The facility failed to obtain physician's order prior to placing Resident #47's knee immobilizer to her right leg. This failure could place residents at risk of not having a physician order followed.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure nursing staffing information was posted in a prominent place readily accessible to residents and visitors that included: the census, the total number and the actual hours worked by the registered nurses, licensed practical nurses or licensed vocational nurses and certified nurse aides directly responsible for resident care per shift for 1 of 3 days (04/15/2025) reviewed for required postings. The facility failed to ensure the daily staffing information for licensed and unlicensed nursing staff was posted in a prominent location on 04/15/2025. This failure could place residents, their families, and visitors at risk of not knowing how many nursing staff were currently working and the total hours were to be worked by nursing staff to provide care on all shifts. Findings Included: During an observation on 04/15/2025 at 10: [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free from misappropriation of property for one (Resident #7) of 5 residents reviewed for misappropriation of property. The facility failed to ensure Resident #7 was free from misappropriation of property when AP borrowed money for personal benefit. The non-compliance was identified as past non-compliance dated 1/24/25. The facility had corrected the noncompliance on 1/28/25 before the survey began. This failure could place residents at risk of exploitation/misappropriation of property and financial distress.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure 5 pies were covered when being stored in the refrigerator. This failure could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure that residents receive care, consistent with professional standards of practice, to prevent pressure ulcers and do not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 (Resident #4) residents reviewed for pressure ulcers. The facility failed to provide care as ordered to bilateral heel pressure ulcers. The facility failed to assess pressure ulcers weekly. The facility failed to provide interventions to prevent development or worsening of Resident #4's heel pressure ulcers. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who needed respiratory care were provided respiratory care consistent with professional standards of practice for 1 of 1 resident (Resident #5) reviewed for oxygen administration. The facility failed to place nebulizer mask and tubing in a bag and date when replaced. The facility failed to obtain physician's order prior to supplying oxygen to resident. The facility failed to monitor oxygen concentrator tubing connected appropriately. The facility failed to date humidifier on oxygen concentrator when replaced. These deficient practices could place residents who received oxygen and treatments at risk of respiratory infection.

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 to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of two residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1. This failure could place residents at risk for the spread of infection.