Northeast Rehabilitation and Healthcare Center

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to privacy of personal mail delivered to the facility for 1 of 3 residents (Resident #1) reviewed for resident rights. The facility failed to ensure staff did not open a letter with a check personally addressed to Resident #1 on 4/19/26. This deficient practice could compromise the residents' right to confidential communication and personal privacy.

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 time frames to meet residents' medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 13 residents (Residents #1, #2, and #3) reviewed for care plans. 1. The facility failed to develop a care plan to address Resident #1 had wandering behaviors.2. The facility failed to develop a care plan to address Resident #2 had a diagnosis of other stimulant abuse.3. [...]

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (1) of one (1) kitchen (Kitchen 1) reviewed for food safety requirements. 1. Food service staff failed to ensure an unidentified nursing staff member wore hair restraints while in the kitchen during meal preparation on 05/17/2026. 2. Food service staff failed to ensure personal foods and beverages were not kept in the kitchen refrigerator and freezer on 05/19/2026. 3. Food service staff failed to ensure a facility contracted chemical supplier representative wore hair restraints while in the kitchen during meal preparation on 05/20/2026. These failures could place residents at risk for the spread of infections, food contaminations, food-borne illnesses, and diminished quality of life.

Inspectors wroteBased on interviews and record reviews, 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 one (1) of two (2) residents (Resident #78) reviewed for clinical records. The facility failed to ensure Resident #78's wound care treatments were accurately documented on her Treatment Administration Records for 14 of 222 scheduled wound care treatments from 12/22/2025 to 05/18/2026. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 11 (Medication Aide G, CNA H, CNA I, CNA J, CNA K, Dietary Supervisor, Activity Director, Operations Manager, ADON L, RN D, CNA M) of 28 employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured Medication Aide G, CNA H, CNA I, Dietary Supervisor, ADON L, and Operations Manager received required training within 21 days of hire, per facility's training policy. The facility failed to implement and maintain a training program that ensured CNA J, CNA K, Activity Director, and RN D received required training annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on 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 and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 1 of 6 Residents (Resident #118) reviewed for pharmacy services. The facility failed to ensure LVN F documented that she provided the Medication Aide a Dronabinol capsule (a controlled medication prescribed for protein malnutrition and appetite stimulation) on the Controlled Substance Administration Record for May 2026 for Resident #118. This deficient practice could put residents at risk of misappropriation and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 6 medication carts (Medication Aide cart for half of C unit and all of D and E unit) reviewed for storage: The facility failed to ensure Resident #118's Dronabinol capsule (a controlled medication prescribed for protein malnutrition and appetite stimulation) was stored appropriately in the medication cart. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions.

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 6 residents (Resident #116 and #10) reviewed for infection control:The facility failed to ensure RN N wore proper PPE while providing indwelling urinary catheter care to Resident #116 who was on EBP status and failed to use appropriate hand hygiene when moving from a clean area to a dirty area when administering medications to Resident #10. These failures could place residents at risk for cross-contamination and infection and could result in illness due to improper care practices.

Inspectors wroteBased on interview and record review the facility failed to develop policies and procedures to ensure the resident's medical record included documentation that indicated, at minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization and influenza immunizations and that the resident either received the pneumococcal immunization and influenza immunizations or did not receive the pneumococcal immunization and influenza immunization due to medical contraindication or refusal for 1 of 10 residents (Resident #10) reviewed for immunizations. The facility failed to ensure Resident #10 had record of receiving education or being offered the pneumococcal vaccine and influenza (flu) vaccine. This failure could cause residents to be vulnerable to preventable diseases and illness.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective communications training for 4 (CNA J, CNA K, Activity Director, Operations Manager) of 28 employees reviewed for training, in that: The facility failed to ensure effective communication training was provided to Operations Manager within within 21 days of hire, per facility's training policy. The facility failed to ensure effective communication training was provided to CNA J, CNA K or Activity Director annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide resident rights training for 1 (Operations Manager) of 28 employees reviewed for training, in that: The facility failed to ensure resident rights training was provided to Operations Manager within 21 days of hire, per facility's training policy. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory training on abuse prevention and dementia management training for 1 (RN D) of 28 employees reviewed for training, in that: The facility failed to ensure abuse prevention training was provided to Activity Director annually. The facility failed to ensure dementia management training was provided to RN D annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 2 (CNA J and Operations Manager) of 28 employees reviewed for training requirements. The facility failed to ensure required QAPI training was provided to Operations Manager within 21 days of hire, per facility's training policy. The facility failed to ensure required QAPI training was provided to CNA annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 2 (Activity Director and Operations Manager) of 28 employees reviewed for training, in that: The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided to Operations Manager within 21 days of hire, per facility's training policy. The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided to Activity Director annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory ethics training for 2 (CNA J and RN D) of 28 employees reviewed for training, in that: The facility failed to ensure ethics training was provided to CNA J or RN D annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure CNAs received the required minimum 12 hours annual in-services for 3 of 8 (CNA J, CNA K, CNA M) CNAs reviewed for trainings requirements. The facility failed to provide the required 12 hours of annual training to CNA J, CNA K, and CNA M. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory behavioral health training for 4 of 28 (Dietary Supervisor, Activity Director, Operations Manager, ADON L) employees reviewed for training requirements was completed. The facility failed to ensure behavioral health training was provided to Dietary Supervisor, Operations Manager, or ADON L within 21 days of hire, per facility's training policy. The facility failed to ensure behavioral health training was provided to Activity Director annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 1 of 2 residents (Resident #1) reviewed for monitoring of applied knee immobilizers. The facility failed to develop and implement supports and monitoring systems for Resident #1's need for a right knee immobilizer, and the resident developed skin breakdown underneath the knee immobilizer. This failure could place residents at risk for injuries from unmonitored orthotic devices.

Inspectors wroteBased on observations, interviews, and record reviews, 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 2 residents (Resident #1) reviewed for a care plan. The facility failed to develop and implement a care plan for Resident #1's physician prescribed right knee immobilizer. This failure could place residents at risk of not having care instructions for orthopedic appliances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 2 residents (Resident #1) reviewed for accurate records. Resident #1's medical records contained skin assessments which documented Resident #1 had no knee immobilizer. This failure could place residents at risk for inaccurate medical records.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect or exploitation were reported no 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 State Survey Agency for 2 of 4 residents (Residents #1 and #2), reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report to the State Survey Agency (HHSC) an incident that occurred on 12/27/25-12/28/2025 in which Resident #1 received a package delivery intended for Resident #2 that contained multiple baggies of a crystal-like substance suspected to be narcotics. This failure could place residents at risk for neglect and could lead to a diminished quality of life and physical harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, residents received treatment and care and services in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 13 residents (Resident #7) reviewed for quality of care. The facility failed to ensure Resident #7 received care and services according to professional standards when Resident #7, who was on blood thinners, fell before noon on [DATE] and received orders for monitoring and neuro checks. The last neuro check was completed at 2:45 a.m. on [DATE]. Resident #7 was last seen at 4:30 a.m. on [DATE]. Resident #7 was found unresponsive at approximately 7:20 a.m., with EMS services activated at 7:28 a.m. on [DATE] and she expired. [...]

Inspectors wroteBased on interviews and record reviews, 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 13 residents (Resident #7) reviewed for clinical records. The facility failed to document Resident #7's verbal aggression and room change, time or location of fall, monitoring and neuro check orders from physician, or pain and skin/injury assessment on 10/02/2025. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident had the right to be free from abuse for 1 of 11 residents (Resident #3) reviewed for abuse. The facility failed to ensure Resident #3 was free from verbal abuse when LVN-H said to the resident Shut up on 04/04/2025. These failures could place residents at risk of feelings of indignity, irritability, and sadness. The noncompliance was identified as PNC (Past Non-Compliance). The noncompliance began on 04/04/2025 and ended on 04/05/2025. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on observation, 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 nursing needs that were identified in the comprehensive assessment for 2 of 3 Residents (Resident #1 and Resident #2 reviewed for mechanical lift transfers. MDS Coordinator, LVN C failed to identify that Resident #1 and Resident #2 were transferred via mechanical lift on their Care Plan. This deficient practice could affect any resident and could result in staff not providing the required services during transfers.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure it provided assistive devices to each resident to prevent avoidable accidents for 1 of 2 Residents (Resident #1) who were observed for mechanical lift transfers. CNA A and CNA B failed to use proper technique when transferring Resident #1 from the wheelchair to the bed on 8/20/25. CNA B walked away from Resident #1 while in mid-air, swinging side to side and while CNA A was attempting to position the mechanical lift under Resident #1's bed. CNA A continued to maneuver the mechanical lift on her own without CNA B's assistance as required according to facility policy. This deficient practice could affect residents who were transferred via mechanical lift, result in avoidable accidents and contribute to serious bodily injuries and possible death. The findiings were: [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records in accordance with accepted professional standards and practices for one (Resident #4) out of seven residents reviewed for documentations. The facility failed to document wound care dressing changes on the Treatment Administration Record (TAR) for Resident #4 on 08/15/2025, 08/16/2025, and 08/17/2025. These failures placed residents at risk for missed treatments and care which could result in the wound deterioration, and development of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 3 nurse medication carts and 2 of 24 residents (Resident #89 and Resident #66) reviewed for storage of drugs and biologicals. 1. The facility failed to ensure Resident #89 did not have medications at the bedside when a large bottle of antacids was found at the resident's bedside. 2. The facility failed to ensure Resident #66 did not have medications at the bedside when a bottle of hemp gummies and a bottle of blood flow supplements were found at the resident's bedside. 3. The facility failed to ensure medication carts were locked and secured when LVN M left a medication unlocked and unsecured on 03/20/2025. These failures could place residents at risk of medication misuse or drug diversion.

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 date a bag of whipped cream in the fridge. 2. The facility failed to keep dry food delivery off the floor. 3. The facility failed to take and log temperatures for alternate items prior to meal service. 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 control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 3 of 3 residents (Residents #22, Resident #49, and Resident #147) reviewed for infection control. 1. The facility failed to ensure PTA O wore a gown while in providing care to resident #22 who was on EBP. 2. The facility failed to ensure CNA N performed hand hygiene and changed gloves during incontinent care on Resident #49. 3. The facility failed to ensure ADON B used appropriate infection control principles, including hand hygiene/glove changes during wound care. [...]

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 2 of 2 residents (Residents #46 and Resident #49) observed for physical restraints in that: 1. The facility failed to obtain a consent for Resident #46 to wear a wander guard. 2. The facility failed to obtain a consent for Resident #49 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, interviews, and record review, the facility failed to ensure the residents had the right to formulate an advanced directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 (Resident #22) of 8 residents reviewed for accuracy and completeness of clinical records. The facility failed to ensure Resident #22's OOH DNR was signed by 2 witnesses. This failure could affect any residents who have medical records and could result in misinformation about professional care provided.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 19 residents (Resident #91) reviewed for assessments: Resident #91's admission assessment MDS dated [DATE] did not accurately reflect the resident could not be rated for incontinence since the resident required an indwelling urinary catheter. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interviews and record review, the facility failed to identify a diagnosis of mental illness on the preadmission screening and resident review (PASRR) assessment for 2 of 2 residents (Resident #47 and Resident #90) whose records were reviewed for PASRR services. The facility failed to recognize on the Level I PASRR screening that Resident #47 and Resident #90 had the mental illness diagnosis of bipolar disorder which would qualify Resident #47 and Resident #90 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 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 24 residents (Resident #89) reviewed for accidents and hazards: The facility failed to ensure Resident #89 did not have a pair of scissors, a large pair of nail clippers, and a disposable razor in his room. This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections for 2 of 5 residents (Resident #49 and Resident #91) reviewed for incontinent care: 1. The facility failed to ensure CNA I and CNA N properly cleaned Resident #31's vaginal area, catheter tube, and buttock area during incontinent care. 2. The facility failed to ensure Resident #91's indwelling urinary catheter bag was not on the floor. These deficient practices could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 residents (Resident #9) reviewed for oxygen therapy: Resident #9's oxygen concentrator filters were covered in a thick white/gray substance. This failure could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery.

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 3 residents (Resident #9) reviewed for dialysis: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Resident #9. 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 all alleged violation 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 caused the allegation involved abuse or resulted 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 1 of 6 residents (Resident#2) reviewed for abuse and neglect. 1. The facility failed to report to the state survey agency an allegation of abuse reported by a family member of Resident #2. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated for 1 of 6 residents (Resident #2) reviewed for abuse. The facility failed to thoroughly investigate an allegation of abuse involving Resident #2. This failure could place residents at risk of allegations of abuse causing mental, physical or emotional harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 8 residents (Residents #1 and #2) reviewed for resident assessments, in that: 1. The facility failed to ensure Resident #1 was coded on his Quarterly MDS, dated [DATE], for a physical behavior that occurred on 06/12/2024. 2. Resident #2's Discharge MDS , dated 06/30/2024, was inaccurately coded as discharged to Home/Community instead of to Hospital. 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 post daily 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 6 days (07/31/2024 to 08/05/2024). The facility did not post the required current nurse staffing information from 07/31/2024 to 08/05/2024. 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 record review and interview, the facility failed to complete an assessment which accurately reflected the resident's status for 4 of 24 residents (Residents #8, #32, and #33) reviewed for resident assessments, in that: 1. The facility failed to complete a BIMS for Resident #8 prior to the submission of the resident's quarterly MDS. 2. The facility failed to complete a BIMS for Resident #32 prior to the submission of the resident's quarterly MDS. 3. The facility failed to complete a BIMS for Resident #33 prior to the submission of the resident's quarterly MDS. These failures could result in inadequate care due to an incomplete assessment of the residents' mental status.

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 3 of 3 residents (Resident #388, #9 and #65) reviewed for dialysis, in that: The facility did not maintain communication, coordination, and collaboration with the dialysis facility for Residents #388, #9 and #35. 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 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 60% based on 15 out of 25 opportunities, which involved 8 of 13 Residents (Residents #14, #24, #27, #36, #38, #56, #57, and #99) reviewed for medication administration, in that: 1. The facility failed to ensure LVN B administered 8 medications within acceptable parameters for safe medication administration for Residents #14, #24, #36 #38, #56 #99 and #57. 2. The facility failed to ensure LVN C administered Resident #27's medications via PEG tube according to physician orders. 3. The facilty failed to ensure LVN C administered the correct medication to Resident #27 when LVN C administered a capsule of amantadine with out physician orders. [...]

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. There was plastic storage container of food thickener in the dry storage room that was not properly sealed. 2. There was a clear plastic bag with pieces of raw bacon in the reach in cooler that was not sealed, labeled or dated. 3. There was a box containing individual portions of roll dough in the walk in freezer that was open and the bag inside the box was open. 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 maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of infections for 3 of 5 staff (LVN B, LVN C, and CNA G) reviewed for infection control, in that: 1. The facility failed to ensure CNA G sanitized the blood pressure cuff between Resident #81, #83, #100, and #101. 2. The facility failed to ensure LVN B did not enter Resident #9's room without the proper PPE for droplet precautions. 3. The facility failed to ensure LVN C did not touch Resident #27's medication with his bare hands during administation. These deficient practices could place residents at-risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the residents' right to confidentiality in his or her personal and medical records for 1 of 1 residents (Resident #80) reviewed for residents' rights, in that: The facility failed to ensure LVN C locked Medication Cart Hall D/E Computer and left Resident #80's information exposed. This failure could place residents at risk of resident-identifiable information being accessed by unauthorized persons.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 5 residents (Resident #1) reviewed for indwelling urinary catheter care, in that: Resident #1's indwelling urinary catheter drainage bag was on the floor. This failure could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional standard for 2 of 13 residents (Resident #24 and Resident #81) reviewed for storage of drugs. 1. The facility failed to prevent an unlabeled IV bag of normal saline hanging on an IV pole in Resident #81's room. 2. The facility failed to ensure LVN B administered an insulin that had been open 41 days prior, 13 days past the expiration date, to Resident #24. 3. The facility failed to ensure LVN C did not leave a medicine cup containing 2 tablets of acetaminophen unsecured and unattended on top of the nurse medication cart. These deficient practices could place residents at risk of medication not meeting therapeutic levels, misuse and diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 1 of 1 non-designated smoking areas, in that: The facility failed to ensure there was a self-closing ash tray, fire blanket, or sign designating an area a smoking area. This deficient practice could result in harm to residents and staff due to improperly discarded and used cigarette butts if policies were not followed.

Inspectors wroteBased on interview, and record review, the facility failed to provide and document sufficient preparation to ensure safe and orderly discharge from the facility for one resident (Resident #1) of three residents reviewed for discharge. The facility failed to assure all the resident's medications were reviewed and provided when Resident #1 discharged home. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for anxiety or depression.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents had the right to be free from abuse for 1 of 5 (Resident #6) residents reviewed for abuse, in that: Resident #6 was involved in an altercation on 02/20/2023 in which CNA F verbally abused, shouted in a threatening manner, and spoke offensive language to Resident #6. The non-compliance was identified as past non-compliance. The non-compliance began on 02/20/2023 and ended on 02/22/2023. The facility had corrected the non-compliance before the investigation began. This failure could affect the residents at the facility and place them at risk for physical, verbal, and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to incorporate recommendations from a PASRR evaluation report into a resident assessment, care planning, and transition of care for 1 of 1 resident (Resident #7) reviewed for PASRR services, in that: The facility failed to submit a NFSS authorization request for PASRR specialized services (therapies and assessments OT and PT) through the TMHP Long Term Care (LTC) Portal for Resident #7 in the required timeframe. This failure could place residents at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 of 5 licensed staff (LVN A) reviewed for nursing competencies. The facility failed to ensure LVN A followed the physician's orders to test (Resident # 3) for COVID-19[Corona Virus Disease] not (resident # 2 ). This failure had the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide care that was safe and capable of minimizing accidents from procedural errors and errors in medication administration.

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 two residents of 5 residents (Residents #2 and #3) observed for infection control, in that: LVN A failed to identify resident # 2 prior to conducting COVID-19 test [Corona Virus Disease] , leading to incorrect results reported and delay in treatment for Resident # 3 . This deficient practice could potentially affect Residents in the facility by placing them at risk of contracting, spreading, and/or exposing them to pathogens that could lead to the spread of communicable diseases.

Inspectors wroteBased on 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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (R#1), reviewed for care plan development. R#1 had a seizure on 07/12/23 requiring a hospitalization for three days and the care plan was not revised to reflect a goal and interventions for seizures. This deficient practice could place residents at risk for lack of coordination of services and continuity of care.