Pearsall Nursing and Rehabilitation Center

Inspectors wroteBased on interviews, and record review, the facility failed to ensure the resident assessment accurately reflected the resident's status for 1 of 6 residents (Resident #17) reviewed for resident assessments. The facility failed to ensure Resident #17's MDS assessment dated [DATE] correctly assessed the resident received dialysis treatments. These failures could place residents at risk for inadequate care and services.

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. 1 of 6 residents (Resident #97) reviewed for pharmaceutical services. LVN B did not prime (a safety test used prior to injecting a patient with insulin in which the dosage selector is dialed to waste at least 2 units of insulin and if insulin solution is seen at the tip of the needle it ensures an accurate dose is injected) the insulin pen prior to injecting Resident #97 with insulin. This deficient practice could affect residents who received insulin by a flex pen in the facility by not receiving the intended therapeutic benefit of their medication.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide special eating equipment for residents who needed them and appropriate assistance to ensure that the resident could use the assistive devices when consuming meals for 1 of 1 resident (Resident #24) reviewed for special eating equipment and assistance when consuming meals. The facility failed to ensure Resident #24 received the physician-ordered slow-flow adaptive drinking cup during the noon meal on 07/13/2026. The failure placed Resident # 24 at risk for aspiration and/or aspiration pneumonia. Record review of Resident #24's face sheet dated 06/11/2024 revealed Resident #24 had a diagnosis including dysphagia (medical term for difficulty swallowing) and a history of stroke (a medical emergency that happens when blood flow to part of the brain stops, causing brain cells to die from lack of oxygen). [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 1 resident (Resident #23) reviewed for hospice services, in that: The facility failed to ensure Resident #23's hospice documents including: The hospice election form and the physician certification and recertification of the terminal illness specific to each patient were present in the hospice binder in the facility. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation. [...]

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 1 of 5 residents (Residents #97) reviewed for infection control:During the medication pass, the facility failed to ensure LVN B did not touch the water faucet with his bare hand after washing his hands and wiped the rubber seal to Resident #97's insulin pen with an alcohol swab prior to administering insulin. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 1 of 6 Residents (Resident #9) whose MDS records were reviewed for accuracy. Resident #9's Discharge MDS assessment dated [DATE] incorrectly documented the resident was discharged to a Short-term hospital. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #1) of 5 residents reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #1 on 05/23/2025, CNA-A did not clean the resident's buttock area. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to maintain the temperature of reach-in cooler #1 at or below 41 degrees F. 2. The facility failed to ensure a package of pork sausage and a package of sliced salami were discarded by their use-by dates. 3. The facility failed to record the temperature of reach-in cooler #1 on the Refrigerator Temperature Record on 05/08/2025. 4. The facility failed to properly sanitize the compartments of the blender used to puree food for modified diets in accordance with manufacturer's instructions. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #92) of 8 residents reviewed for baseline care plans. The facility failed to include Resident #92's use of antipsychotic medication in his baseline care plan. This failure could result in residents not receiving needed care and treatment. Findings Included: [...]

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 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 8 residents (Resident #89) reviewed for care plans: The facility failed to ensure Residents #89's Care Plan reflected he should receive PASRR services. This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received necessary treatment and services, consistent with professional standards of practice to promote wound healing and to prevent new pressure ulcers from developing for 1 of 2 residents (Resident #61) reviewed for pressure injuries. The facility nurse did not provide wound care to Resident #61 on the evening of 05/07/2025 as ordered. This failure could place residents at risk of improper wound management, deterioration in existing pressure injuries, infection, and pain.

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 medication cart (300 Hall medication cart) reviewed for storage of drugs. The Facility failed to provide change direction labels for Resident #86's medication package of sertraline (Sertraline is an SSRI (serotonin reuptake inhibitor) that increases serotonin levels between neurons (nerves) by blocking serotonin from being absorbed.) which had medication order change from 150 mg to 50 mg. This deficient practice could place residents at risk of medication misuse and diversion.

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 2 of 8 residents (Residents #69 and #45) reviewed for infection control. 1. The facility failed to ensure CNA -G, after completing peri and foley care for Resident #69, did not replace a bed wedge that had fallen on the floor back onto Resident #69's bed without cleaning/sanitizing it first. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 22 residents (Resident #44, Resident #47 and Resident #95) reviewed for resident rights. 1. The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #44 Representative prior to admitting to a locked unit. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure 1(NA A) of 1 Nurses' Aides were not working in the facility longer than four months without being enrolled in or having completed an approved training course. The facility failed to ensure NA G was a certified nursing aide (CNA) within the required time frame. This failure place residents at risk for receiving care from an individual whose skill level was not known.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 24 residents (Resident #95) reviewed for advanced directives, in that: The facility failed to ensure Resident #95's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and signed by the physician which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on record review and interviews, the facility failed to complete an accurate assessment which reflected the resident's status for 1 of 5 residents (Resident #78) reviewed for unnecessary medications. The facility failed to ensure Resident #78's diagnosis of depression was included in the residents annual MDS assessment on 01/31/2024. This failure could result in inadequate care due to an incomplete assessment of the resident's psychological condition.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments person-centered care plan to reflect the current condition for 1 of 22 residents (Resident #44) reviewed for care plan revisions. 1. The facility failed to ensure Resident #44's care plan was comprehensive and updated to reflect Resident #44 resided on a locked unit, listed her allergies, listed her code status, and contained interventions for her dementia diagnosis. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 3 resident (Resident #47) reviewed for incontinent care, in that: The facility failed to ensure CNA G properly cleaned Resident #47 vaginal area after an incontinent episode. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on record review and interviews, the facility failed to administer a psychotropic medication to treat a specific, diagnosed condition for 1 of 5 residents (Resident #78) reviewed for unnecessary medications. Resident #78 was being administered a psychotropic medication (Paroxetine, an antidepressant used to treat depression) since 01/12/2024 without having an active and current diagnosis of depression. This failure could result in residents receiving unnecessary medications.

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 2 of 4 medication cart (100 hall and 500 Hall medication cart) reviewed for storage of drugs. The Facility failed to provide change direction labels for 2 medications packages which had their medication orders changed. This deficient practice could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all dietary staff were confirmed to have appropriate competencies and skillsets to carry out the functions of food and nutrition service for 1 of 1 facility (Activity Director) reviewed for food preparation. The activity director was concluded on 03/27/2024 to be preparing food for resident use without having evidenced a food handlers' certificate to the facility. This failure could place all residents who consume food prepared during activities at increased risk of food-borne illness and not receiving adequate nutrition.

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 safely for 1 of 1 facility reviewed for kitchen sanitation. The facility failed to discard all past dated food in the activities refrigerators, and ensure all food items contained a label in the activities freezer and kitchen Freezer #5 as observed on 03/27/2024. This failure could place all residents who consume food prepared by facility staff at increased risk of food-borne illness and not receiving adequate nutrition.

Inspectors wroteBased on observations, interview and record reviews, the facility failed to ensure the resident environment was as free of accident and hazards as possible for 3 of 5 halls (100 hall, 200 hall, and 300 hall) reviewed for accident and hazards, in that: 1. The facility failed to prevent a container of unsecured bleach wipes from being found on the 100 hallway. 2. The facility failed to ensure the door to the utility area was locked and the room housing hazardous material was locked on the 200 hallway. 3. The facility failed to ensure the supply room containing small objects and food items was unlocked on the 300 hallway which was a secure unit for residents with cognitive concerns. These deficient practices could result in residents coming into contact with dangerous materials which could place them at risk of injury or death.