Navasota Nursing & Rehabilitation

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prompt efforts were made by the facility to resolve grievances for one (1) of five (5) Residents (Residents #1) reviewed for grievances, in that; The facility did not investigate or take prompt action to resolve grievances voiced by Resident #1's RP during a care plan meeting on 06/10/2026 regarding his wishes for Resident #1 not to be given morphine sulfate (narcotic pain reliever) unless he was first notified and that he would like to add a routine acetaminophen to take the edge off and prevent the use of morphine sulfate which caused the resident sedation and confusion. This deficient practice could place facility residents at risk of unresolved grievances, a decreased sense of self-worth, and a decline in quality of life. Findings Included: [...]

Inspectors wroteBased on interview 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 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 one of five residents (Resident #1) reviewed for care plans. The facility failed to revise a comprehensive care plan to reflect Resident #1's RP's wishes for her pain medication administration. These failures could place residents at risk of not receiving appropriate interventions to meet their psychosocial and medical needs.

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 1 of 3 medication carts (Medication Cart #1) reviewed for drug storage and labeling. The facility failed to ensure Medication Cart #1, was locked, medications secured, and not accessible to other staff, residents, or visitors and was left unlocked by RN A two times at 6:49 a.m. and 7:30 a.m. on 06/23/2026. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received care and services, consistent with professional standards of practice to maintain skin integrity to prevent the development of pressure ulcers and other skin conditions for three (Resident #1, Resident #3 and Resident #4) of four residents reviewed for skin integrity. The facility failed to consistently complete, and documents required skin checks weekly for three residents (Resident #1, Resident #3 and Resident #4). This failure put residents at risk for undetected skin issues, worsening skin issues and decreased quality of life.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure each resident was treated with respect, dignity and care for 1 of 6 residents (Resident #2) observed for resident rights. The facility failed to ensure Resident #2's door was closed when provided with personal care on 5/5/2026. This failure could place residents at risk of feeling embarrassed, loss of dignity and decrease in quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the call light system was adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from residents room for 1 of 6 (Resident #1) residents reviewed for resident call system. The facility failed to ensure the call light system in Resident #1's room was functioning on 05/05/2026. This failure could place residents at risk of harm by not being able to call for help when needed and at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation and interview, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 2 of 2 days (05/05/2026 - 05/06/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information from 04/29/2026 to 05/05/2026. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on interview, and record review the facility failed ensure the comprehensive care plan, consistent with resident rights, included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of five residents (Resident #1) reviewed for care plans completion. The facility failed to ensure Resident #1's care plan was completed to reflect Resident #1 was lying on a mattress located on the floor and was crawling on the floor toward his roommate's bed. This failure could place residents at risk of not receiving appropriate interventions to meet their medical and safety needs.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing activity program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 3 of 59 residents reviewed for activities. The facility failed to provide activities for all residents in the facility for the entire months of August 2025 and September 2025. This failure could place residents at risks of boredom, depression, behavior, diminished quality of life and decreased cognitive function.

Inspectors wroteBased on interview, and record review , the facility failed to ensure a resident who was diagnosed with a mental illness or psychosocial adjustment difficulty, or who had a history of trauma and/or post-traumatic stress disorder, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for four (Resident #1, Resident #2, and Resident #3 ) of five resident reviewed for behavioral health. The facility failed to ensure Resident #1, Resident #2, and Resident #3 received appropriate psychiatric services. This failure could place residents at risk because their mental and psychosocial needs not being met and a decreased quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure the residents had the right to be free from abuse and neglect for two (Resident #2 and Resident #5) of four residents reviewed for abuse and neglect. The facility failed to protect Resident #2 from physical abuse by Resident #5. This failure placed residents at risk of abuse, neglect, trauma, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accidents and hazards as possible for 1 of 3 shower rooms reviewed for accidents and supervision. The facility failed to ensure the shower door located on Mc [NAME] Hall was closed and locked. This failure could place residents at risk of injuries, illness, and hospitalization.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents received care and services consistent with professional standards of practice to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 (Resident #1) of 3 residents reviewed for pressure ulcers. The facility failed to:A. Ensure Resident #1 had appropriate interventions in place to prevent unstageable pressure ulcers under her C- Collar neck brace. B. Perform thorough skin assessments under Resident #1's C-collar to ensure pressure ulcers were not developing. C. Ensure Resident #1's C-collar was applied properly and maintained, as it was noted to be taped in place to prevent removal, with fecal matter smeared on tape. These failures resulted in an Immediate Jeopardy (IJ) situation on 09/17/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure CNA A, on 07/30/25, did not transfer Resident #1 from his bed to a shower chair without using two people and a mechanical lift. Resident #1 fell and suffered pain to his right ankle and behind his right knee. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 07/30/25 and ended on 07/30/25. The facility had corrected the noncompliance before the survey began. This deficient practice placed residents at risk of pain, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for one of three ([NAME] Hall) medication carts reviewed for medication storage. The facility failed to ensure [NAME] Hall medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors. This failure could place residents at risk of having unauthorized access to prescription, biologicals, and over-the-counter medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal for five of six residents (confidential residents) reviewed for grievances. The facility failed to post the grievance procedure in a prominent and accessible locations throughout the facility; provide residents with access to grievance forms, and instruction on how to file an anonymous grievance. This failure could place residents at risk by limiting their access to the grievance process, which may result on unresolved concerns that impact their well-being and overall quality of care.

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 nutrition, grooming and personal and oral hygiene for 3 of 11 residents (Residents # 11, #17, and #32) reviewed for ADLS . 1. The facility failed to ensure Resident #11's fingernails were cleaned, trimmed and filed. 2. The facility failed to ensure Resident #17 received baths per her care plan and her request and failed to ensure her nails were trimmed. 3. The facility failed to ensure Resident #32 had clean clothing, failed to ensure she received baths three times a week and failed to ensure her nails were trimmed and filed. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one of six residents (Resident #39) reviewed for quality of care. The facility failed to take vital signs daily for 58 of the last 68 days per the QAPI initiated physician orders for Resident #39. This failure could place residents at risk of not receiving necessary medical care and lead to an unacknowledged change in condition and possible hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with the professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure a hair net was worn by Dietary Aide . These failures could place residents who ate food served by the kitchen at risk of food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one of two medication carts (RN medication cart) reviewed for medication safety. The facility failed to ensure that a loose Tramadol pill (controlled medication) in RN Medication Cart was secured, administered, and/or disposed of based on facility policy. The failure puts residents at risk for not receiving their prescribed medication and risk of possible drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide or obtain from an outside source dental service to meet the needs of 1 of 4 residents (Resident #33) reviewed for dental services. The facility did not assist Resident #33, who had missing teeth and pain when she ate , with a dental service consult. This failure could place residents at risk of oral complications, pain, difficulty eating, and diminished quality of life.

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 six residents reviewed for infection control practices. (Resident #52). The facility failed to ensure that LVN B used gloves to open a capsule prior to medication administration on 6/4/2025. This failure could place the resident at risk for cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility and post in a place accessible to residents, family members and legal representatives of residents, the results of the most recent survey of the facility for 6 of 57 reviewed for rights to survey results. The facility failed to ensure survey results were not posted in a location readily accessible and visible to residents, their legal representatives, or family members. This failure could place residents at risk of having their rights limited to access information regarding the facility's compliance with state and federal requirements.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services by sufficient numbers of nurse aides and licensed nurses on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 6 of 8 shifts (04/19/25 06:00 AM-06:00 PM, 04/19/25 06:00 PM-06:00 AM, 04/20/25 06:00 AM-06:00 PM, 04/20/25 06:00 PM-06:00 AM , 04/21/25 06:00 AM-06:00 PM , and 04/22/25 06:00 AM-06:00 PM) reviewed for sufficient nurse staffing. The facility failed to schedule nurse aides and licensed nurses in numbers consistent with the posted nurse staffing during the following shifts: 04/19/25 06:00 AM-06:00 PM, 04/19/25 06:00 PM-06:00 AM, 04/20/25 06:00 AM-06:00 PM, 04/20/25 06:00 PM-06:00 AM , 04/21/25 06:00 AM-06:00 PM , and 04/22/25 06:00 AM-06:00 PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 3 of 6 residents (Residents #1, #2, & #3) reviewed for resident rights in that: Residents #1, #2, & #3 's call lights was not within reach on 01/30/2025. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on 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 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 1 of 6 residents (Resident #3) reviewed for comprehensive care plans. Resident #3's comprehensive care plan did not reflect Resident #3's received psych service. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 6 residents (Resident #4) reviewed for care plans. The facility failed to ensure Resident #4's care plan was updated to reflect the resident's recent falls on 12/20/2024, 01/24/2025 & 01/25/2025. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on observation and interview, and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 7 (01/24/2025, 01/25/2025. 01/26/2025. 01/27/2025. 01/28/2025. 01/29/2025, and 01/30/2025) of 8 days reviewed for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 01/24/2025, 01/25/2025, 01/26/2025, 01/27/2025, 01/28/2025, 01/29/2025, and 01/30/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the representative when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure Resident #1's MD was notified after she experienced swelling in her left arm. Resident #1 complained of pain 11/16/2024, the Medical Doctor was not informed. On 11/20/2024 the Medical Doctor assessed the resident and ordered an X-ray which showed no significant findings on 11/21/2024 of which the MD was not notified. [...]

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice, and accounted for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #1) of 1 resident reviewed for trauma informed care. The facility had Resident #1 in a shared room with Resident #2, when his care planning for Post-Traumatic Stress Disorder (PTSD) documented that having roommates triggers his PTSD. This failure could place residents at increased risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive care consistent with professional standards of practice, to prevent pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and once developed, failed to ensure necessary treatment and services to promote healing for one (Resident #21) of six residents reviewed for pressure ulcers. The facility failed to ensure Resident #21 who was at risk for skin breakdown was turned every two hours and provided incontinent care. on 05/07/2024, Resident #21 was left in the same position in her Geri-chair (specialized recliners that are upholstered in non-permeable, easily sanitized vinyl.) for 6 and a half hours from 8:00 AM till 2:30 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to provide a private space for residents' monthly resident council meetings and the confidential resident group meeting during survey for five of five confidential residents reviewed for resident council. The facility did not provide a private space for resident council meetings. The failure could place residents, who attended resident council meetings, at risk of not being able to exercise their rights of being able to voice their grievances in a private space without uninvited staff being present. Findings Included: Interview on 05/07/2024 10:10 AM, the Administrator stated the residents would be in the dining area that it was located next to the nurses' station which was an open room with no doors for privacy. After speaking with the administrator, the meeting was then moved to the Activity Directors office. [...]

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 grooming and personal hygiene for 5 of 10 residents (Resident #3, Resident #4, Resident #20, Resident #46, and Resident #61) reviewed for ADL's. A) The facility failed to ensure assistance was provided for repositioning and incontinent care every 2 hours for Resident #4, and Resident #20. B) The facility failed to ensure Resident #3, Resident # 46 and Resident #61's nails were cleaned. These failures placed residents at risk for a decline in health, skin breakdown, loss of self-esteem, and a diminished quality of life and could result in health-related issues from lack of hygiene. Findings Included: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide, based on comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choices of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interest of and support the physical, mental, and psychosocial well-being of each resident, encouraging interaction in the community for 4 of 8 residents (Resident #4, Resident #20, Resident #21, and Resident # 61) reviewed for activities. Residents #4, #20, #21, and Resident #61 were not receiving one-on-one activities or involved in group activities during the months of February, March, April, and May of 2024. This failure could place residents at risk for a decline in social, mental, psychosocial well-being, and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to prepare puree food by methods that conserve nutritive value, flavor, and appearance for 1 of 1 kitchen observed for puree preparation. The facility failed to follow the puree diet recipes. The puree diet meatloaf was mixed with water instead of thickener or a broth with nutrient value. This failure could affect residents on puree diet at risk of receiving inadequate diet that could affect their health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for foods safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure food that was prepped was labeled and dated. The facility failed to maintain proper temperatures of food before putting on the steam table. This failure placed residents at risk of foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 9 (Resident # 39) residents in 1 of 3 dining rooms. The facility failed to promote Resident # 39's dignity while dining when staff did not serve his lunch tray for 20 minutes after his tablemate was served. This failure could affect all residents who were eating in the dining room, by contributing to poor self-esteem, and unmet needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of each resident's needs for 2 (Resident #45 and Resident #46) out of 14 reviewed for call lights. The facility failed to ensure Resident #45 and Resident #46's call lights were within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive care plan 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 one resident (Resident #18) of eight reviewed for indwelling urinary catheters care plans, in that: The facility failed to ensure Resident #18's Comprehensive Care Plan reflected his use of an indwelling urinary catheter. These failures could place residents with indwelling urinary catheters at risk for urinary tract infections, change of condition and risk for not having their individually assessed needs met which could result in a diminished quality of care and staff being unaware of needed interventions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for two of five residents (Resident #4 and Resident #20), reviewed with limited range of motion. A) The facility failed to ensure Resident #4 had interventions in place for her bilateral hand contractures (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM) to prevent further decline of the range of motion in her hands and failed to ensure her fingernails were trimmed. B) The facility failed to ensure Resident #20 had interventions in place for her right-hand contracture to prevent further decline of the range of motion in her right hand. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are incontinent of bladder receive appropriate treatment and services to prevent urinary tract infections for one of four residents reviewed for catheters. (Resident #18) The facility failed to ensure Resident #18 received care to prevent urinary tract infections when they stored his catheter bag on the floor and failed to ensure a catheter secure device was in place to prevent dislodgment. These failures could place residents with foley catheters at risk for urinary tract infections and change of condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who displayed or was diagnosed with dementia received the appropriate treatment and services to attain or maintain his or her highest practicable physical, mental, and psychosocial well-being, for one of 12 residents (Resident #18) reviewed for residents with dementia and behaviors. The facility failed to develop and implement a comprehensive person-centered care plan to address Resident #18's continuous behaviors regarding his indwelling catheter. This failure could place residents at risk for their medical, physical, and psychological needs not being met and placed residents with indwelling catheters at risk of urinary tract infections and traumatic removal of the catheter leading pain and injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of communicable diseases for two of four residents reviewed for infection control. (Residents #22 and #32) LVN A failed to sanitize the common glucometer, which is used during blood testing between resident blood sugar checks. This failure could lead to contamination of the nurse cart and potential resident exposure to blood-borne diseases. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 14 residents (Residents #1 and 2) reviewed for quality of care. The facility failed to ensure TLVN and LVN C assessed and reported a new new skin injury to Resident #1's first two toes of the right foot and a new skin injury to Resident #'s first and fifth toes of the right foot. An Immediate Jeopardy (IJ) situation was identified on 03/06/24. While the IJ was removed on 03/08/24 at 03:00 PM., the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid and incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 5 residents (Resident #3) reviewed for PASARR coordination. The facility failed to ensure specialized OT, PT and ST evaluations and therapies were effectively requested for Resident #3 within three business days of a PASARR IDT meeting on [DATE] in which the services were agreed to be necessary. This failure placed residents at risk of not attaining the highest practicable well-being possible.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement written policies and procedures that ensured reporting of crimes in federally funded long-term care facilities in accordance with section 1150B of the Act, any incident that involved an emergency situation that posed a threat to resident health and safety immediately, but not later than 24 hours after the incident occurs or is suspected. The facility failed to: 1. The facility failed to report to State Survey Agency (HHSC), immediately, but not later than 24 hours, when, on [DATE], two employees witnessed another employee with a gun in the facility. 2. [...]

Inspectors wroteBased on interviews and record review, the facility failed to protect the residents right to request, refuse, and/or discontinue treatment for one (Resident #1) out of three residents reviewed for advanced directives, in that: The facility failed to ensure Resident #1's DNR was signed by the MD until [DATE] when it was ready to be signed on [DATE]. Resident #1's DNR was not uploaded into the EHR, resulting in LVN A having an incomplete OOH-DNR form with which to make her determination of whether to begin CPR. This failure also resulted in Resident #1's Care Plan reflecting a now incorrect code status at the time Resident #1 became unresponsive. These failures resulted in LVN A performing CPR for 5 minutes, and in 911 being called, who continued CPR for an additional 30 minutes, intubated Resident #1 and transported Resident #1 to the hospital. An IJ was identified on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the completion of a significant change assessment for 1 (Resident #34) of 8 residents reviewed for Significant Change Assessments. The facility failed to ensure Resident #34 had a significant change assessment completed following the discharge from hospice service. This failure could place residents at risk of not receiving adequate services and reimbursement to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a PASRR screening was completed for residents with a mental disorder or an intellectual disability for 1 of 6 residents (Resident #25) reviewed for PASRR Level I screenings. The facility did not ensure an accurate PL1 screening (a preliminary assessment completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) was completed for Resident #25. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 3 residents (Resident # 64) reviewed for wound care. Facility failed to ensure the scissors were sanitized before using it to cut wound care supplies while providing wound care to Resident #64 This failure could place the residents at risk for cross contamination and infection.