Morada Temple

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 storage, food safety, and nutrition services for 1 of 1 kitchen. 1. The facility failed to ensure that food was stored in sealed, airtight packages in the freezers and food on kitchen surfaces are securely covered and closed when not in use.2. The facility failed to ensure kitchen staff wore facial hair restraints when preparing and serving food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement within seven days and make available to staff a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental/psychosocial needs that were identified in the comprehensive assessment for one (Resident #28) of six residents reviewed for care plans in that: The facility failed to ensure Resident #28 had a comprehensive person-centered care plan implemented in the EMR.This failure could place residents at risk of not receiving the necessary care to meet his medical, nursing, and psychological needs. Findings Included:A record review of Resident #28's Face Sheet reflected an [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and were not accessible to unauthorized staff, visitors, and residents for one (Medication Cart A on North Hall - Rooms 301 - 316) of two medication carts reviewed for medication storage in that: Medication Cart A was unattended and unlocked outside a resident room, facing outward, in the middle of the hallway. This failure could allow residents, visitors, and unauthorized staff unsupervised access to prescription medication. Findings Included:An observation on 9/3/2025 at 4:19 PM revealed Medication Cart A was left unattended and unlocked. There was a silver key ring with 10-12 keys attached, laying on the top of Medication Cart A. There were no staff and no residents visible to the surveyor. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide routine and emergency drugs and biologicals to its residents or obtain them for 1 (Resident #1) of 6 residents reviewed for pharmacy services. The facility failed to ensure Resident #1 received her routine Midodrine medication for low blood pressure on 06/27/25 at 7:00 p.m. and 06/28/25 at 7:00 a.m. Resident #1's blood pressure was low, which made her feel dizzy and lightheaded. This failure could place residents at risk of hypotension, accidents, injuries, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for eight (8) of seventeen (17) dietary staff reviewed for qualified dietary staff, in that: The facility failed to ensure the DS#1, DS#2, DS#3, DS#4, DS#5, DS#6, DS#7 and DS#8 had their Texas Food Handler Certificate. This failure could place residents who ate food from the facility's kitchen at risk of not having their nutritional needs met and place them at risk for food born illnesses.

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 reviewed for food and nutrition services. 1. The facility failed to ensure kitchen staff (Cook E, Server F, Server G and Server H, and the dishwasher) wore mustache or beard guards and hair coverings while in the kitchen . 2. The facility failed to ensure food in the freezer, refrigerator, and dry storage room was properly stored, dated and labeled. 3. The facility failed to ensure the kitchen was free of pests/insects. 4. The facility failed to properly thaw chicken. These failures could place residents at risk of 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 4 of 5 residents (Residents #6, #1, #14 and #27) reviewed for infection control . 1. MA I failed to properly sanitize the blood pressure cuff when moving from one resident to another resident when administering medications and obtaining the blood pressure for Residents #1, #14 and #27. 2. RN A failed to wash or sanitize her hands while going from a dirty to clean surface while performing wound care for Resident #6. These deficient practices could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 2 of 5 residents (Resident #6 and Resident #13) reviewed for assessments. The facility failed to accurately document in the assessment Resident #6 and Resident #13's dental status. This failure could place residents at risk of inadequate care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were unable to conduct activities of daily living (ADLs) received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for three of ten residents (Resident #9, Resident #287 and Resident #238) reviewed for quality of life. 1. The facility failed to ensure Resident #238's nails were cleaned and trimmed. 2. The facility failed to ensure Resident #238's chin hair was trimmed. 3. The facility failed to ensure Resident #9, Resident #287 and Resident #238 chin hairs were trimmed. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 5 residents (Resident#3) reviewed for pharmaceutical services. The facility failed to ensure Resident #3's Micrabegron Extended Release (prescribed to treat overactive bladder) tablet was not crushed. This failure could place residents at risk of discomfort or decrease residents quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 5 of 5 residents (Resident #s 1, 2, 3, 4, and 5) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was assessed for safety regarding hot liquids resulting in Resident #1 sustaining 1st and 2nd degree burns on 02/23/2024 when he spilled his coffee on himself and was not assessed for hot liquids safety after the incident. The facility failed to have a system in place to assess for hot liquid safety and to ensure Residents #2, #3, #4, and #5 were being served hot coffee with safety interventions assessment or potential interventions in place. [...]

Inspectors wroteBased on Interview and record review, the facility failed to protect the resident right to request, refuse and/or discontinue treatment for 1 (Resident #1) of 34 residents reviewed for advance directives. The facility failed to ensure Resident's # 1 OOHDNR was processed and updated in EMR and care plan when signed by physician on [DATE]. The resident had a seizure on [DATE] that resulted in life saving measures being given, as the EMR showed resident was a full code, AED was applied and shock given, CPR was started, and resident was transferred to the hospital . An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of No actual harm with potential for more than minimal harm that was not Immediate Jeopardy and a scope of isolated. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan to include the minimum healthcare information necessary to properly care for a resident for 1 of 24 residents (Resident #1) reviewed for baseline care plans. The facility failed to update Resident #1 baseline care plan on [DATE] when his code status changed from Full code to DNR, resulting in Resident #1 receiving CPR and the use of an AED which delivered a shock on [DATE] the Resident # 1 suffered a seizure and stopped breathing. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a severity level of actual harm that was not Immediate Jeopardy at a scope of isolated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to follow physician orders and the resident's advance directives for 1 of 35 residents (Resident #1) whose records were reviewed for DNR code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff did not provide Resident #1, who had a DNR in place, CPR started after the resident had a seizure and stopped breathing, according to professional standards of practice. On [DATE] Resident # 1 had a seizure and stopped breathing, was listed as a full code in the EMR. Life saving measures were initiated. Upon review of the medical record order signed by the physician on [DATE] out-of- hospital do not resuscitate. Resident #1 had an out of hospital do not resuscitate singed on [DATE] and signed by the physician on [DATE] in the medical record. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain medical records in accordance with accepted professional standards and practices for each resident that are complete, accurately documented, readily accessible, and systemically organized for one (Resident #1) of 35 residents reviewed for medical records. The facility failed to ensure Resident #1 had the most current physician's order in the EMR for code status that was changed by a written physician's order in the paper chart. This failure could place residents at risk of having records that do not reflect their current status resulting in potential prolonged suffering, pain, physical injury and psychosocial harm due to receiving CPR against physicians' orders. Findings Included: [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to implement a comprehensive person-centered care plan for eight (8) of eight (8) residents (Residents #1 through Resident #8) reviewed for care plans. The facility failed to ensure Resident #1 through Resident #8's care plans were updated and revised to reflect a recent COVID infection. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in injury and a decline in physical well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all drugs and biologicals were stored in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 1 (Medication cart #1) of 6 medication/treatment carts reviewed for medication storage in that: Medication Cart #1 left unattended and unlocked. This failure could allow residents, unsupervised access to prescription and over the counter medications. Findings Include: Observation on 10/19/2023 at 08:21 am Medication cart # 1 was in the hallway unlocked and unattended. Two residents were in the area at the time. At 08:22 am RN A approached and asked if I needed anything, Surveyor pointed out that the medication cart was unlocked RN A looked and stated she was unaware cart was not locked. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's kitchen in three (Refrigerator #1, Walk-In Cooler #2 and Walk-In Cooler #3) three refrigerators and two (Ice Machine #1 and Ice Machine #2) out of two ice machines in the kitchen. The facility failed to date and label opened stored leftover foods in the three out of three refrigerator/coolers. The facility failed to ensure meat being thawed was not stored next to fully cooked meet in Refrigerator #2. The facility failed to ensure two of two ice machines were clean; pink/orange slime and black spots were observed inside the ice bin. These failures could place at risk of foodborne illness and decreased product quality.

Inspectors wroteBased on interview and record reviews the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, for two of five residents reviewed for unnecessary medications. (Residents #6 and #7) A) The facility failed to ensure a PRN order for Lorazepam (anti-anxiety) dated 05/30/2023 had a stop date to ensure the medication did not extend beyond 14 days for Resident #6. B) The facility failed to ensure a PRN order for Lorazepam (anti-anxiety) dated 06/09/2023 and Seroquel (antipsychotic) dated 05/02/2023 had a stop date to ensure the medication did not extend beyond 14 days for Resident #7. [...]

Inspectors wroteBased on interview 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, are reported immediately, but no later than 2 hours after the allegations is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) for 1 of 1 resident (Resident #9). The facility failed to ensure that an incident of Neglect/Injury of Unknown Origin, was reported immediately to HHSC when Resident #9 allegedly fell on [DATE], which resulted in a right hip fracture. This failure could place the residents at risk for unreported allegations of abuse, neglect, and injuries of unknown origin.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1 had their oxygen tubing routinely changed and their oxygen concentrator filter routinely changed. This failure could place residents at risk of experiencing nose irritation and nose bleeds, thus not having their respiratory needs met.

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 and follow accepted national standards for one of two residents (Resident #184) reviewed for wound care. The facility failed to ensure LVN A followed standard precautions during wound care for Resident #184's right foot surgical wound when he failed to establish a clean field for treatment supplies, perform hand hygiene, and gloves changes. These failures could place residents at risk for developing wound infections.