Paradigm at Katy

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for three of four residents (Resident #36, Resident #22, and Resident #66) reviewed for ADLs.1. The facility failed to provide nail care to Resident #36.2. The facility failed to apply lotion to Resident #22 skin.3. The facility failed to shave Resident #66's chin hairThese deficient practices could place residents at risk of skin breakdown and reduced feelings of self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that food was prepared by a method that conserved nutritive value, flavor, and apperance in one of one kitchen. The facility failed to ensure that California blend vegetables and Parmesan chicken for dinner were not cooked 5 hours prior to dinner service. This failure places all residents who ate meals prepared by the kitchen at risk of not getting the nutrients needed to prevent malnutrition and weight loss. Observation on 5/20/2026 at 11:45am of the kitchen revealed California vegetables (carrots, broccoli and cauliflower) on the stove top cooking. In the oven there was parmesan chicken cooking. In an interview on 5/20/2026 at 11:47 am with [NAME] F she said the vegetables and chicken were for dinner. She said dinner starts serving around 4:45pm. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 5 residents (Resident #73) reviewed for call lights. The facility failed to have a call light within reach for Resident #73. This failure could place residents at risk for a delay in care and services, increased falls, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of six residents reviewed (Resident #6) for pressure ulcers. 1. The facility failed to ensure Resident #6 received treatment as ordered to promote healing of sacral and ischial pressure ulcers on 5/20/26These failures could place residents at risk for worsening existing wounds or development of new pressure ulcers. Review of Resident #6's face sheet dated 05/20/26 reflected a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for one (Resident #22) of five residents reviewed for podiatrist services. The facility failed to ensure Resident #22 was seen by a podiatrist for fourth and fifth discolored long toenails. The facility failed to ensure Resident #22's big toenail, which was 75% separated from the nail bed, was addressed. This failure could have placed residents at risk for skin tears and infection because of not receiving foot care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 5 residents (Resident #66, and Resident #6) reviewed for incontinent care. The facility failed to ensure CNA J provided peri care during foley catheter care for Resident #66. The facility failed to ensure CNA PP properly cleaned Resident #6 during incontinent care when CNA PP did not clean around Resident #6's buttocks on 05/20/2026. These failures could place residents at risk for pain, infection, injury, and hospitalization. Findings IncludedRecord review of Resident #66's face sheet dated 05/21/26 revealed he was initially admitted to the facility on [DATE] and readmitted on [DATE] from the hospital. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to restore, if possible, oral eating skills and to prevent complications of enteral feeding including but not limited to aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities and nasal-pharyngeal ulcers for 1of 6 residents (Resident # 6) reviewed for continuous gastrostomy tube feedings. The facility failed to keep Resident #6's head of bed elevated while receiving continuous gastrostomy feedings. This failure could place residents at risk for aspiration pneumonia (lung infection caused by inhaling liquids or vomiting into airway) and unwanted hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 5 residents (Resident #17) reviewed for respiratory care. The facility failed to ensure Resident #17's oxygen humidifier bottle on the oxygen concentrator had water to function properly. This failure could place residents who required respiratory treatments at risk of receiving inadequate respiratory treatments and could result in a decline in health. Record review of Resident #17's face sheet dated 5/19/2026 revealed he was a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents are free of any significant medication error for 2 of 8 residents (Resident #49& #86) reviewed/observed for medication. The facility failed to ensure that Resident #86's blood pressure medication Midodrine was held within the parameter the physician ordered. LVN A failed to follow on 05/21/26 the parameters ordered for Resident # 46's medication metoprolol 50mg ER (extended release) 1 tablet by mouth BID to hold if systolic blood pressure was less than 110 and heart rate less than 60. Resident #46's systolic blood pressure was 108/52. This failure could have placed Residents # 46 and Resident #86 at risk for elevated blood pressure at risk of fainting or a stroke due to not getting their blood pressure medication as ordered by their physician. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections that included, at a minimum, a system for preventing and controlling infections for 1 of 8 residents (Resident #6) and 1 of 2 staff (CNA PP) reviewed for infection control. - The facility failed to ensure CNA PP washed or sanitized her hands and performed glove changes appropriately while providing incontinence care to Resident #6 on 05/20/26. This deficient practice placed residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the facility 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 for 1 of 1 call light systems reviewed for resident call system in that: The facility failed to provide a reliable and effective nurse call system and timely staff response. This failure could result in delayed staff response and placed residents at risk of respiratory compromise and injury related to delayed call light response. Interviews on 12/13/2025 at varies time between 1:00PM - 3:00PM with direct care staff (CNA D, Staff J, Nurse A, RT A) stated that the facility nurse call system does not provide audible alerts which could be heard and relied on staff visually monitoring hallway lights. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment which included injuries of unknown sources and misappropriation of resident property in accordance with state law through established procedures and the facility failed to report the results of all the investigations to the administrator or his or her designated representative and to other officials in accordance with the state law which included to the survey agency within 5 working days of the incident and if the alleged violation was verified appropriate corrective action must be taken for 1 of 4 residents (CR #1) reviewed for abuse and neglect. -The facility failed to report results of a self-reported incident when CR #1 had a fall with injury and was sent to the hospital on [DATE]. [...]

Inspectors wroteBased 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 diseases and infections for one (Hallway A) of four hallways observed for infection control. -CNA K left her hooded jacket and eyeglass case of the clean linen cart in Hallway A.This failure could place the residents at risk of cross-contamination and development of infection. During an observation and interview with RN C of a clean linen cart on Hallway A on 11/19/2025 at 12;19pm, there was an eyeglass case laying directly on top of a black zip-up jacket which was laying on top of the green mesh covering of the clean linen cart. The wheeled cart contained folded linen sheets and briefs inside the mesh cover. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 3 of 4 residents (Resident #33and Resident #56, and Resident #15) reviewed for ADLs. - The facility failed to ensure Resident #33, and Resident #56 were provided incontinent care in a timely manner by facility staff. - The facility failed to ensure Resident #15 was provided personal grooming (cut resident long classified toenails) by facility staff. These failures placed residents a risk for skin break down, offensive odors, and decrease in quality of life.

Inspectors wroteBased on observation, interviews, and record review the facility failed to provide, based on the preferences of each resident, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 5 of 5 confidential residents reviewed for activities. The facility failed to provide activities to meet the residents' interests on Saturdays and Sundays for 5 confidential residents. These failures placed residents at risk for decline in quality of life, social and mental psychosocial wellbeing. Findings Include: Observation on Sunday, 04/27/2025 from 01:00 p.m. to 06:00 p.m. revealed there were no activities visible provided for residents in the activity area. Later observation on 04/28/2025 from 8:00 a.m. to 1:00 p.m. revealed there were no activities visible provided for residents in the activity area. Interview on 04/27/2025 at 02: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #19) of 4 residents reviewed for resident rights. - The facility failed to place Resident #19's foley catheter bag inside of a privacy bag. This failure could affect the residents who require assistance with their ADLs from facility staff by placing them at risk for social isolation, loss of dignity, and self-worth.

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 timeframes to meet a resident's medical, nursing, and mental and psychosocial needs and describes 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 5 residents (Resident #34) reviewed. -The facility failed to ensure that Resident #34's status of oxygen was a focus area in the resident's comprehensive care plan and no intervention was in place. This deficient practice could affect residents by contributing to inadequate care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible for 1 of 6 (Resident #13) resident rooms observed for accident hazards. -Resident #13's room had two bottles of hair products on their dresser not stored in a safe manner on 4/27/2025. This failure could place residents at risk of injury due to unnecessary access to potentially harmful substances.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #56) reviewed for incontinent care. The facility failed to ensure CNA V properly cleaned Resident #56 during incontinent care when CNA V did not separate Resident #56's labia on 04/27/2025. This failure could place residents at risk for pain, infection, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #11) of 7 residents reviewed for enteral nutrition. The facility failed to follow physician orders for Resident #11 enteral feeding tube to be administer 55ml (milliliters) high-protein tube-feeding formula 1.5 calories (cal) every hour (hr). This failure could place residents who had gastrostomy tube at risk for fluid overload.

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) to meet the needs of each resident for 1 of 6 residents (Resident #71) reviewed for pharmacy services. -Resident #71 had Ipratropium .02% solution with 22 plastic vials (respiratory treatment), Ipratropium .02% nebulizer solution with 15 plastic vials, and Budesonide inhalation (respiratory treatment for Crohn's and asthma) suspension of .5mg/ml in medication cart A, even though Resident #71 had discharged from the facility. The failure of not disposing of discharged residents' medications could potentially cause a decline in their health condition and further injury if they were accidentally administered another resident's medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 carts (Cart B) reviewed for medication labelling. - LVN V's cart (cart B) had one undated Lidocaine vial (used to treat pain) with injection marks in the seal. These failures could cause medications to be given past their expiration date, potentially leading to ineffective therapeutic effect.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 facility dumpsters observed for proper garbage disposal -Dumpster A's side door was observed open with trash inside on 4/27/2025. This failure could place residents at risk of contact with pests and associated diseases.

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 diseases and infections for 2 (Resident #19 and Resident #13) of 14 residents reviewed for infection control. - The facility failed to ensure Resident #19 foley catheter tubing was off the floor. - The facility failed to ensure Resident #19's floor mat was free from his foley catheter tubing. - - Resident #13's room had two bottles of hair products with other resident's names on them on the dresser on [DATE]. These failures placed residents, staff and visitors at risk for cross contamination, unwanted infections, and decease in quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 6 (Resient #1) reviewed for supervision in that: -The facility failed to ensure CNA A did not improperly reposition Resident #1 by pulling his arm on 03/24/25. This failure could place residents at risk of being injured, bruised, or have fractured limbs . Findings Include: Record review of Resident #1's face sheet revealed a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 13 of 28 residents (Resident #1, #2, #3, #4, #5, #6, #8, #9, # 10, #11 #12, #13, and #14) reviewed for infection control. The facility failed to ensure residents (Resident #1, #2, #3, #4, #6, #7 #8, #9, # 10, #11, #12, #13, #14) did not acquire Candida auris (Candida auris is a fungal infection that can cause serious illness) infection at the facility. The facility failed to ensure staff (CNA B and LVN M) wash or sanitize hands after providing care to Residents (Resident #2, #3, #4, #5, #6 and #7) rooms. [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to be 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 each resident's bedside and toilet and bathing facilities for 4 of 4 halls (100 Hall, 200 Hall, 300 Hall, and 400 Hall) reviewed for call light systems. 1. The facility failed to repair or replace the call light system for the entire building after five months when inclement weather caused the system to fail on 05/02/2024 through 10/09/2024. Resident #2, Resident #3, and Resident #4, who were all physically and cognitively capable of using a call light system had no means to call for staff assistance. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care on accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 10 residents (CR #1) reviewed for quality of care. The facility failed to ensure the night shift staff (10:00 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care for 1 of 10 residents (CR #1) reviewed for comprehensive Person-Centered Care Planning. The facility failed to develop a baseline care plan for CR #1 that addressed his communication status/needs, tracheostomy/ventilator status/needs, and his nighttime anxiety. This failure placed newly admitted residents at risk of not receiving the care and services specific to their needs.

Inspectors wroteBased on interview and record review, the facility failed to be administered in a manner that enables it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of all r esidents reviewed. -The Administrator failed to ensure the staff had gloves readily available to staff to provide care for the residents. This failure could cause residents not to receive care or delay of care resulting in an increase in infections and hygiene concerns .

Inspectors wroteBased on 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 resident's choices for 2 of 2 residents (CR#1 and CR#2) reviewed for quality of care. 1. The facility failed to ensure emergency medical treatment was provided in a timely manner to CR #1, after he missed 3 to 4 days of dialysis, his doctor gave orders for hospital evaluation and treatment, and the Dialysis Nurse expressed concerns of fluid overload. 2. The facility failed to ensure emergency medical treatment was provided in a timely manner to CR#2, after his doctor gave orders for a blood transfusion, which was an emergency situation. An Immediate Jeopardy (IJ) situation was identified on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who required dialysis received such services, consistent with the professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (CR # 1) reviewed for dialysis. The facility failed to ensure CR # 1 received hemodialysis treatments as ordered by his physician. CR # 1 exhibited symptoms of fluid overload and required emergency medical care. In addition, Resident #1's dialysis access port malfunctioned, and Resident # 1 did not receive dialysis for 4 days. CR # 2 missed dialysys treatments on [DATE] and [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] at 2:50 pm. [...]

Inspectors wroteBased on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective action was taken for 6 of 6 Residents (Resident #7, #8, #9, #10, #11, #12) reviewed for allegations involving abuse, physical environment, and infection control. 1. The facility failed to complete a Provider Investigation Report for 3 of 3 intakes involving Resident #7, #8, #9, #10, #11, #12. These failures could place residents at risk for abuse, injury, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care, including tracheotomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the 'residents' goals and preferences for one of two residents (Resident #1) reviewed for tracheotomy care. 1. The facility failed to ensure sterile technique when Resident #1 changed her inner cannula on 05/15/24. 2. The facility failed to ensure Resident #1's MD was notified Resident #1 changed her inner cannula on 05/15/24, per facility policy. These failures could place residents at risk for respiratory infections, hospitalizations, and a decline in overall quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 3 call light systems (call light #2) reviewed in 1 of 2 shower rooms reviewed. The facility failed to ensure that call light #2 in shower room [ROOM NUMBER] was maintained in safe operating condition. These failures could place residents at risk of not receiving emergency care in a timely manner and at risk for fire emergencies.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or a centralized staff work area for 1 of 3 call light systems (call light #2) in 1 of 3 (shower stall #2) in 1 of 2 shower rooms (shower room [ROOM NUMBER]) reviewed for call lights. The facility failed to ensure shower stall #2's emergency call light system in shower room [ROOM NUMBER] had a cord enabling it to be reachable from the floor. The facility failed to ensure that call light #2 in shower room [ROOM NUMBER] was maintained in safe operating condition. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed 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 for one of four resident halls (200-Hall) reviewed for resident call systems. The facility failed to ensure that the rooms on the 200-Hall had working call lights in the restrooms. This failure could place residents at risk of not being able to have their needs met and call for staff assistance when they needed it.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are incontinent of urine received appropriate treatment and services to prevent urinary tract infections for 3 out of 3 residents (Resident #266, Resident #80 and Resident #92) reviewed for Foley catheter care. - The facility failed to ensure Resident # 266's foley catheter bag and privacy bag were not touching the floor while Resident #266 was in bed. - CNA B did not separate Resident #80's labia to clean during incontinent care, clean around the buttocks and did not perform appropriate hand hygiene with glove changes throughout the care. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 4 medication carts (200 hall medication aide cart, and 400 hall nurse cart) reviewed for medication storage. - The 200-hall medication aide's cart contained the following discontinued medications: Centrum Silver Woman 50 plus, Calcium 200mg, PreserVision AREDS 2, and Garlique 60 capsules. -The 400-hall nurse's cart contained an insulin Lispro injection pen100 units/ML((U - 100)3ml prefilled pen that was not stored in its original packet and did not include the pharmacy label or administration instructions. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living (ADLs) received the necessary services to maintain nutrition, grooming and personal and oral hygiene for 1 of 5 residents (Resident #47) reviewed for ADLs. 1. The facility failed to ensure Resident #47 was provided personal grooming (fingernail care) by facility staff. This failure could place residents at risk for discomfort, and dignity issues.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the state for 1 of 1 Activity Director (AD) reviewed, in that: The facility failed to have a qualified AD to serve as the director of the activities program. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with limited range of motion received appropriate treatment and services to prevent a decline in range of motion for 1 (Resident #80) of 3 residents. The facility failed to ensure Resident #80 had interventions in place for her right- hand contracture (A permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen and a decrease in ROM ( Range of motion) to prevent further decline of the range of motion in her right hand. This deficient practice placed residents with contractures at risk for decrease in mobility, range of motion, and could contribute to worsening of contractures. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment was as free of accident hazards as possible for 1 of 1 activities room reviewed for accident hazards, in that: The facility failed to prevent a long neck lighter from being found in 1 of 1 activities room. These deficient practices could result in residents coming into contact with dangerous materials which could place them at risk of injury or death.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 16% based on 4 errors out of 25 opportunities, which involved 3 of 8 residents (Resident #20, Resident #16 and Resident #269) reviewed for medication errors. 1-RN A left a substantial amount of acetaminophen/codeine 300mg/30mg and Sucralfate 1 gm on the portion cup after medication was administrated through g tube to Resident #20. 2-LVN C administered stool softener instead of Senna Syrup 8.8mg/5ml give 10 ml, to Resident # 16. 3-LVN D administered Prednisolone acetate drop, suspension 1%, to both eyes instead of one drop to the right eye to Resident #269 This failure could place residents at risk for increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 3 of 8 residents (Resident #16, Resident #92 and Resident #107) observed for infection control. - RN B failed to clean around Resident #92's draining wound bed during sacral wound treatment. - Respiratory Therapy (RT) entered 2 isolation rooms without donning PPE. Resident #16 and Resident #107 This failure could place the residents at risk for infection.

Inspectors wroteBased on observations and interviews the facility failed to provide a safe functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 2 entrance door to the facility by the laundry) The facility failed to ensure that stored 26 soiled biohazard boxes, syringes, insulin syringes, lancets, GTube formula bag outside by laundry services were not accessible to all staffs and visitors. Findings Included: During an observation on 03/13/2024 at 3:01 PM with Infection Preventionist (IP) the following observations were made: [...]

Inspectors wroteBased on record review and interview, the facility failed to assess each resident annual assessment using the MDS form specified by the state and approved by CMS for 1 of 10 residents (Resident 52) reviewed for annual assessments. Resident #52's Annual MDS Assessment was not completed within 96 days of the previous MDS assessment. This failure could place all residents at-risk of not having their assessments completed timely.

Inspectors wroteBased on interview and record review, the facility failed to complete a resident assessment frequently than once every 3 months for 10 of 19 residents (Resident #14, Resident #15, Resident #34, Resident #46, Resident #63, Resident #85, Resident #86, Resident #87, Resident #93, and Resident #96) reviewed for resident assessments in that: - Resident #87's Quarterly Minimum Data Set's (MDS) for January of 2024 was not completed until 03/15/2024. - Resident #14, Resident #15, Resident #34, Resident #46, Resident #63, Resident #85, Resident #86, Resident #93, and Resident #96's Quarterly MDS' assessment for February of 2024, were not completed until 03/14/2024 and/or 03/15/2024. These failures placed residents at risk of not having their assessments completed timely which could result in not having their individually assessed needs met.

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician; and notify the resident representative for 1 of 3 residents (CR #1) reviewed for change of condition, in that, The facility staff failed to immediately notify the physician when CR#1 started vomiting up a brown substance repeatedly on [DATE]. The facility failed to notify the physician that CR #1 insulin NPH was discontinued when CR#1 was having high glucose readings for 6 days. CR#1 was sent out to the hospital on [DATE] and died in the hospital on [DATE]. An Immediate Jeopardy (IJ) situation was identified on [DATE] while the IJ was removed on [DATE] at 3:58pm, the facility remained out of compliance due to the facility's need to evaluate the effectiveness of the corrective systems that were put into place. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 (CR #1) out of 3 residents reviewed for quality of care in that: The facility failed to recognize a change in condition for CR#1 when she began throwing up on [DATE] and some days after, and continuously having extremely high blood glucose levels for 6 days ([DATE] - [DATE]). CR#1 was sent out to the hospital on [DATE] and died in the hospital on [DATE]. The facility delayed in sending CR#1 to the hospital by calling the non-emergency line taking the ambulance over an hour to come when CR#1 was nonresponsive, blood sugar was 598, and O2 Saturation was 88% while on nonrebreather mask with 10 liters oxygen on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services that include procedures to ensure accurate acquiring, receiving, dispensing, and administering of all drugs for 1 of 3 residents (CR #1) reviewed for medications. The facility failed to follow Physician's order to only discontinue insulin Lispro for CR #1, but facility discontinued all insulin (NPH and Lispro), leaving CR #1 with no insulin to administer for CR #1 while CR #1 was having high blood sugar for multiple days. The facility failed to notify the physician that CR #1 insulin NPH was discontinued when CR#1 was having high glucose readings for 6 days. CR#1 was sent out to the hospital on [DATE] and died in the hospital on [DATE]. [...]