Pleasant Springs Healthcare Center

Inspectors wroteBased on observation, interviews, and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 2 of 3 (Residents #13 and #19) reviewed for physical abuse. 1. The facility Administrator failed to implement their abuse policy by removing the alleged perpetrator when the ADON and RN A reported to her on 5/26/2026 that Resident #13 stated CNA B pinched her and was rough with her. 2. The facility Administrator failed to implement their abuse policy by removing the alleged perpetrator during the week of 5/25/2026- 5/28/2026 when Resident #19 told RN A and LVN C that CNA B was rough with her when providing care and told her she did not care if she was fired from this job because she could go work somewhere else. 3. [...]

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure residents were free from abuse for 2 of 3 residents (Residents #13 and #19) reviewed for resident abuse. 1. The facility failed to protect Resident #13 from abuse during the week of 5/25/2026- 5/28/2026, when CNA B grabbed her by the right forearm and forced her to sit down to make her stay in bed which resulted in a bruise to her forearm. 2. The facility failed to protect Resident #19 from abuse during the week of 5/25/2026- 5/28/2026, when CNA B was rough with her when providing care and told her she did not care if she was fired from this job because she could go work somewhere else during the week of 5/25/2026- 5/28/2026. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of the bladder and had an indwelling urinary catheter received appropriate treatment and services for 3 of 4 residents (Resident #2, Resident #45, and Resident #57) reviewed for urinary catheters. 1. The facility failed to ensure Resident #57 was provided with proper foley catheter and incontinent care on 06/03/2026. The facility failed to ensure the split in Resident #57's penis was routinely assessed. The facility failed to ensure Resident #57's physician and family were notified of the split in his penis. 2. The facility failed to ensure Resident #2 had on a catheter strap (urinary drainage bag straps) and CNA N wiped correctly and performed hand hygiene while providing incontinent care on 06/02/26. 3. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide a private meeting space for residents' monthly council meetings for 8 of 8 confidential residents who were reviewed for resident rights. The facility failed to ensure staff or visitors did not disturb the resident council meetings. This failure could place residents at risk of not being able to voice concerns, fear of retaliation, and discomfort due to a lack of privacy.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that the resident environment remains as free of accident hazards as possible for 4 of 6 residents (Resident's #2, #53, #39, and #52) reviewed for accidents.1. The facility failed to ensure Resident #2 had his fall mat down on 06/01/26, 06/03/26 and 06/04/26.2. The facility failed to ensure CNA Q and CNA O locked the mechanical lift during a transfer for Resident #53 on 05/31/26.3. The facility did not ensure Alcohol Wipes and sanitizing spray were not stored on Resident #39's dresser. 4. The facility failed to ensure Resident #52 room was free from a knife. These failures could place residents at risk of injury or harm.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 6 residents (Resident #67), 2 of 3 medication carts (A/B MA Medication Cart and C/D Nurse Medication Cart) and 1 of 1 Medication Storage Room reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #67's medication labels for his gabapentin (medication used for nerve pain and seizures) and metoclopramide (medication used to treat nausea, vomiting, and improves stomach emptying) matched his physician orders. 2. The facility failed to ensure a bottle of Active Liquid Protein on the A/B MA Medication Cart was dated when opened. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for food and nutrition services. The facility did not ensure:1. Food items were labeled and dated.2. [NAME] restraints were worn. 3. The dome covers were not stacked with water pooled between them. 4. The microwave was clean and free of food debris.5. The deep fryer was clean. 6. The ice scoop holder was clean. 7. Food was discarded after 7 days per facility policy or by best by date. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 22 residents (Resident #67, #2, #13, #57, #21, #19, and # 45) reviewed for infection control.1. The facility did not ensure LVN E performed hand hygiene when providing wound care for Resident #67's who had methicillin-resistant staphylococcus aureus also known as MRSA (is a type of staph that can be resistant to several antibiotics) and who put dirty wipes on his bed linen on 06/02/26.2. The facility failed to ensure CNA N performed hand hygiene while providing incontinent care for Resident #2 on 06/02/26.3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 21 residents (Resident #19) reviewed for resident rights. The facility failed to ensure CNA B treated Resident #19 with dignity and respect, when she failed to identify herself and ensured she wore a name badge while providing care to Resident #19. This failure could place residents at risk of decreased self-worth, loss of dignity and trust, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 21 residents (Resident #41) reviewed for resident rights. The facility failed to ensure Resident #41's call light was reasonably accommodated to her needs, and her call light was within reach. This failure could place residents at risk for a delay in assistance and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from chemical restraints (the use of medication to restrict a person's movement or behavior) that were not required to treat the residents' medical symptoms for 1 of 5 residents (Resident #39) reviewed for unnecessary medications. The facility failed to ensure Resident #39 had an appropriate diagnosis on entered orders for her Seroquel, also known as Quetiapine (an antipsychotic medication that treats several kinds of mental health conditions, including schizophrenia and bipolar disorder.) This failure could place residents at risk for adverse reactions and negative side effects from the administration of medication and dependence on unnecessary medications.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 3 (Residents #13 and #19) residents reviewed for reporting physical abuse. 1. The facility failed to ensure the Administrator reported to HHSC, within 2 hours during the week of 5/25/2026- 5/28/2026 when CNA B grabbed Resident #13 by the right forearm and forced her to sit down to make her stay in bed which resulted in a bruise to her right forearm. 2. The facility failed to ensure the Administrator reported to HHSC, within 2 hours on 05/30/2026, when RN A and LVN C reported to her that Resident #19 alleged CNA B was rough with her while providing care. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 1 of 5 residents (Resident #39) reviewed for quality of life. The facility failed to provide communication or translation assistance to effectively communicate with Resident #39. This failure could place residents at risk for declining and diminishing quality of life, and neglect.

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 1 of 3 residents (Resident #57) reviewed for quality of life. The facility failed to ensure Resident #57 was assisted with incontinent care in a timely manner after his brief had brownish residue/spots on it and he had a bowel movement on 06/03/2026. This failure could place residents at risk of not receiving the services and care needed, decreased self-esteem, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident (Resident #67) reviewed for enteral devices. The facility failed to ensure RN H did not administer Resident #67's gabapentin (medication used for nerve pain and seizures) and metoclopramide (medication used to treat nausea, vomiting, and improves stomach emptying) by pushing it through his g-tube (placement of a tube into the stomach used for nutrition and medication administration) with a syringe on 06/01/2026. This failure could affect residents receiving enteral nutrition, medications, and hydration by placing them at risk of health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 2 of 4 residents (Resident #31 and Resident #34) reviewed for respiratory care. 1. The facility failed to ensure Resident # 31's nebulizer face mask was placed in a plastic bag, labeled, and dated. 2. The facility failed to ensure Resident #34 oxygen tubing and water humidifier was dated and changed. These failures could place residents requiring respiratory care at risk for shortness of breath, respiratory distress, or complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 1 of 6 residents (Resident #21) reviewed for pharmacy services. The facility failed to ensure MA G did not administer Resident #21's Vitamin C when there was no dosage listed in the physician's order on 06/01/2026. This failure could place the residents at risk of not having medications available for use, medication errors, and inaccurate records.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 7 residents (Resident #67) reviewed for laboratory services. The facility failed to ensure Resident #67's Microalbumin (Albumin is a protein needed for tissue growth and healing. It can leak into your urine when your kidneys aren't working as they should) was drawn every 6 months as ordered by the physician. These failures could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases.

Inspectors wroteBased on observations, and interviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 2 of 2 residents (Residents #26 and #46) reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 06/02/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate residents' food preferences for 1 of 6 residents (Resident #4) reviewed for nutrition. The facility failed to honor Resident #4's preference for no bread for the lunch meal on 05/31/2026 This failure could place residents at risk for a decrease in resident choices, diminished interest in meals, and weight loss. Finding including: Record review of face sheet dated 06/04/2026 revealed Resident #4 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of bipolar disorder (intense mood swings) and type 2 diabetes (metabolic effecting blood sugar control) Record review of Quarterly MDS dated [DATE] revealed Resident #4 was able to make herself understood and was able to understand others. MDS Assessment indicated Resident #4 had a BIMs score of 15 indicating no cognitive impairment. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that residents who were trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (Resident #1) reviewed for trauma-informed care The facility failed to ensure Resident #1 had an accurate trauma screen that identified she had a history of trauma. This failure could place residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provided supervision to prevent avoidable accidents for 1 of 3 residents (Resident #1) and 1 of 1 shower rooms (Hall C communal shower) reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised after she had been wandering and exit seeking, which resulted in Resident #1 exiting the facility and being found outside the facility in the facility's driveway headed toward a busy public street on 05/17/2025. An IJ was identified on 02/19/2026. The IJ began on 05/17/2025 and removed on 06/13/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 4 halls (Hall C), reviewed for a homelike environment. The facility failed to ensure that Hall C was free of offensive odors. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure residents were free from abuse for 2 of 8 residents (Resident #5 and Resident #2) reviewed for resident abuse. 1. The facility failed to ensure CNA AA and NA Z provided incontinent care and turning and repositioning for Resident #5 every 2 hours on 02/14/26 and 02/20/2026. 2. The facility failed to protect Resident #5 from verbal abuse when CNA BB spoke to Resident #5 in a degrading manner while providing incontinent care to her on 12/15/2025. 3. The facility failed to protect Resident #2 from physical abuse when the ADON hit Resident #2's hand about three months ago. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent mistreatment, neglect, and abuse of residents, for 2 of 8 residents (Resident #2 and Resident #5) reviewed for abuse. 1. The facility failed to implement their abuse policy when the ADON did not report an allegation of verbal abuse to the abuse coordinator after Resident #5's family member reported to her CNA BB spoke to Resident #5 in a demeaning manner on 12/15/25. 2. The facility failed to implement their policy on reporting abuse when Anonymous Staff Member #1 witnessed the ADON hit Resident #2's hand about three months ago and failed to report it to the abuse coordinator. This failure could place residents at risk of unreported abuse, neglect, exploitation, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 4 medication carts (A/B Medication Aide Medication Cart, A/B Nurse Medication Cart, and the C/D Medication Aide Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure the A/B Medication Aide Medication Cart and the A/B Nurse Medication Cart were properly secured, when LVN B went to break, left the facility, and left them unlocked and unattended on 02/18/2026. The facility failed to ensure antifungal powder was stored properly, when it was left on top of the A/B Nurse Medication Cart unattended on 02/18/2026. [...]

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 in 1 of 1 kitchen reviewed for dietary services. The facility failed to ensure:A dented can was stored separately from the undented cans2 opened loaves of bread were stored properly in the dry storage areaAn opened, unsealed carboard box with mushrooms was not stored in the refrigerator directly on top of onions inside a Ziploc bag. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 4 residents (Resident #5) reviewed for dignity. 1. The facility failed to ensure CNA AA treated Resident #5 with respect and dignity when CNA AA provided incontinent care to Resident #5 and did not cover her buttocks when she left the room to gather more supplies on 02/14/26. 2. The facility failed to ensure CNA Q closed the window blinds prior to providing incontinent care for Resident #5 on 02/17/26. These failures placed residents at risk of diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on record review and interview, the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 1 of 5 residents (Resident #6) reviewed for discharge. 1. The facility failed to notify Resident #6's responsible party of his discharge prior to him being discharged from the facility. This failure placed residents at risk of not having an advocate who can inform them of their options, rights, and the added protection from being inappropriately transferred or discharged .

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 1 of 4 residents (Resident #5) and 1 of 3 shower rooms (Hall C shower room) reviewed for infection control practices. 1. The facility failed to ensure CNA S performed hand hygiene and changed gloves when she provided incontinent care to Resident #1 on 02/23/2026. 2. The facility failed to ensure the communal shower room located on Hall C had no soiled towels on the floor or soiled wash cloths on the shower railing, a gown laid folded upon an overflowed trash bin on 02/18/2026. 3. The facility failed to ensure CNA Y covered the 1 of 4 linen carts (Hall A's linen cart) on 02/23/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient CNAs according to the facility assessment on 02/09/2026, 02/13/2026, 02/20/2026. This failure placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 5 residents reviewed for pharmacy services. (Resident #1) The facility failed to accurately administer medications for Resident #1 when LVN A, Medication Aide B, and Medication Aide C administered a medication listed as an allergy. This failure could place residents at risk for inaccurate drug administration. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse or CNA when the facility had an average daily occupancy of 60 or more residents for 16 of 30 days reviewed for DON coverage. 1. The facility failed to ensure the DON did not serve as a charge nurse on 10/28/25. 2. The facility failed to ensure the DON did not serve as a CNA on 10/1/25, 10/4/25, 10/09/25, 10/10/25, 10/12/25, 10/15/25, 10/17/25, 10/18/25, 10/19/25, 10/23/25, 10/24/25, 10/25/25, 10/26/25, 10/28/25, 10/29/25, and 10/30/25. 3. The facility did not ensure the DON was able to do her designated duty of DON in a 40 hour/week due to performing nurse and CNA duties. These failures could leave residents without the nursing administrative oversight that only the DON can provide.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, clean bed and bath linens for 1 of 1 facility reviewed for resident rights. The facility failed to ensure bed pads (cloth pads placed on the bed to protect mattresses and bedding from incontinence) were available for the residents to use. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 3 of 23 residents (Resident #7, Resident #8, and Resident #44) reviewed for care plans. 1. The facility failed to ensure a care plan was developed for Resident #8's left arm fracture, use of a sling to the left arm, and refusal to wear her sling. 2. The facility failed to implement Resident #7's care plan for staff to remain outside of the shower for safety. 3. The facility failed to ensure Resident #44's care plan reflected he had weight loss. These failures could place the residents at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wrote2. Record review of Resident #61's face sheet, dated 01/29/25 indicated she was an [AGE] year-old female admitted to the facility on [DATE] and readmitted [DATE] with diagnoses which included Respiratory failure (a condition where there's not enough oxygen or too much carbon dioxide in your body), Dementia (memory loss), and diabetes. Record review of Resident #61's quarterly MDS assessment, dated 12/04/24, indicated Resident #61 usually understood and was understood by others. The MDS assessment indicated she had a BIMS score of 03 indicating she was severely cognitively impaired. Resident #61 required total assistance with bathing, toileting, dressing, bed mobility, personal hygiene, and eating. The MDS indicated she required oxygen. Record review of Resident #61's physician's order dated 10/04/24 indicated: [...]

Inspectors wroteBased on interviews, 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 2 of 23 residents (Resident # 20 and Resident # 26) reviewed for pharmacy services. The facility failed to ensure Resident #20's blood pressure met the parameters for the administration of an anti-hypertensive medication on 02/06/2025 and on 02/08/2025. The facility failed to ensure Resident #26's blood pressure met the parameters for the administration of an anti-hypertensive medication on 01/12/2025, 01/25/2025, 01/30/2025, 02/08/2025 and on 02/20/2025. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 4 of 23 (Residents #64, #38, #12, and #13) residents and 1 of 3 meals reviewed. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #64, Resident #38, Resident #12, and Resident #13, who complained the food was bland and did not taste good. The dietary staff failed to provide food that was palatable for 1 of 3 meals observed on 02/25/25 (lunch) meal. This failure could place residents at risk for weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to conduct and document a facility-wide assessment to determine what resources were necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to ensure they followed the assessment information about the level of staff needed to meet each resident's needs. This failure could place residents at risk of inadequate care or treatment. Findings Included: A record review of the facility's CMS 802 Resident Matrix dated 02/24/25 revealed the facility census to be 72 residents. During a record review of the facility's assessment dated [DATE] and reviewed by QAPI on 08/21/24, revealed the staffing ratio was for the facility to have 5 aides for 6 am-2 pm, 4 aides for the 2 pm-10 pm, and 4 aides for the 10 pm-6 am shift. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the residents or responsible party had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment, and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #34) reviewed for psychoactive medications. The facility failed to ensure Form 3713 was filled out completely based on Resident #34's diagnostic criteria, and assessment finding exhibited by the resident for the medication Seroquel, also known as Quetiapine (is an antipsychotic medication that treats several kinds of mental health conditions, including schizophrenia and bipolar disorder. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 23 residents (Resident #23) reviewed for grievances. The facility did not ensure a grievance was filed and Resident #23 was appropriately apprised of progress toward a resolution when Resident #23's white pants with black trim, denim shirt with pink cuffs, a blue shirt, and white socks with black and red around the top were not returned from the laundry. This failure could place residents at risk for a decreased quality of life, and grievances not being addressed or resolved promptly.

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 for 1 of 4 residents (Resident #174) reviewed for baseline care plans. The facility failed to develop a baseline care plan that addressed Resident #174's use of oxygen. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives necessary services to maintain personal hygiene were provided for 2 of 72 residents reviewed for ADLs (Resident #58, Resident #70). 1. The facility did not ensure Resident #58 received fingernail care. 2. The facility did not ensure Resident #70 received her showers. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #47) reviewed for accidents and supervision. The facility failed to ensure razors were not kept in Resident #47's bathroom. This failure could place residents at an increased risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident and determines that drug records are in order and that an account of all controlled drugs is maintained and periodically reconciled for 2 of 2 residents (Resident #1 and Resident #2) reviewed for pharmacy services. The facility failed to ensure Resident #2's family member signed the medication release form for medications which included Ativan (also known as Lorazepam, a controlled medication used for anxiety) on 02/09/2024 and 02/16/2024. The facility failed to ensure Resident #2's Ativan was accurately reconciliated when she returned to the facility on [DATE], 02/18/2024, and 12/15/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remained free of accident hazards and each resident was provided adequate supervision to prevent injuries for 1 of 6 residents (Resident #1) reviewed for accident hazards. The facility failed to ensure Resident #1's freestanding closet was secured to the wall resulting in him pulling it down on top of his self when he fell on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death.

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 in (1 of 1) kitchen reviewed for dietary services, in that: 1) The facility failed to seal, label and date refrigerator and freezer food items. 2) Dietary staff failed to dispose of expired foods items in the pantry and refrigerator. 3) Dietary Staff failed to test the dishwasher to ensure dishwasher chemical levels was at 50 PPM or above. 4) Dietary Staff failed to ensure the chemical strips for the 3 compartment sink were not expired. 5) Dietary Staff failed to ensure the ice machine was cleaned. 6) Dietary Staff failed to clean the juice nozzle. 7) Dietary Staff failed to clean the fryer. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment in 19 of 63 Rooms (D hall) reviewed for a clean and homelike environment. The facility failed to ensure (D hall) was cleaned daily, and in accordance with the facility's Housekeeping policy. This deficient practice could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 20 residents (Resident #16, Resident # 37, and Resident #56) reviewed for comprehensive person-centered care plans. 1. The facility failed to care plan Resident #16's CPAP machine (machine used to deliver constant and steady air pressure to help you breathe while you sleep). 2. The facility failed to care plan Resident #56's contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to both hands. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care are provided care, consistent with professional standards of practices for 5 of 63 residents reviewed for respiratory care (Residents #23, #18, #41, #11 and #16). 1. The facility failed to ensure Resident #23's oxygen was in a bag when not in use. 2. The facility failed to ensure Resident #18 and Resident #41 oxygen concentrator filter was cleaned weekly. 3. The facility failed to ensure Resident #41 nebulizer tubing was placed inside a bag after her breathing treatment was administered. 4. The facility failed to ensure Resident #11's handheld nebulizer was stored in a bag. 5. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 1 of 3 meals reviewed for palatability and temperature. The facility failed to provide food that was palatable at the lunch meal on 1/9/24. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

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 3 of 6 staff (CNA B, CNA C, Treatment Nurse) and 2 of 4 Halls (Hall D and Hall A) reviewed for infection control. 1. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while providing wound care to Resident #44. 2. The facility failed to ensure CNA C changed gloves and performed hand hygiene while providing incontinent care to Resident #165. 3. The facility failed to ensure CNA B changed gloves and performed hand hygiene while providing incontinent care to Resident # 60 4. The facility failed to ensure the linen carts on Hall D and Hall A were covered. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure residents have 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 and to choose the option he or she prefers for 1 of 5 residents (Resident #23) reviewed for right to be informed about consents. The facility failed to ensure Resident #23 had signed psychotropic consent for Celexa (antidepressant). This failure could place residents at risk of receiving medications without their prior knowledge or informed consent, or that of their responsible party.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 1 of 20 residents (Resident #12) reviewed for grievances. The facility did not ensure a grievance was filed for Resident #12's black pants with a bow in the front when it was not returned from the laundry. These failures could place residents at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 20 residents (Resident #56) reviewed for MDS assessment accuracy. The facility did not ensure Resident #56's MDS assessment was accurately coded to reflect his limitation in range of motion related to his contractures (a shortening of muscles, tendons, skin, and nearby soft tissues that causes the joints to shorten and become very stiff, preventing normal movement) to both upper extremities. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interviews 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 for 1 of 3 residents (Resident #45) reviewed for baseline care plans. The facility failed to develop a baseline care plan that addressed Resident #45's use of a blood thinner. This failure could place residents at risk of bleeding, excessive bruising, and not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment was free of accidents and hazards for 1 of 4 residents (Resident #16) reviewed for safety. The facility failed to ensure Resident #16 did not have an electric heating blanket in his room. This failure could place residents at risk for burns and injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident received appropriate treatment and services to prevent urinary tract infections for 1 of 4 residents (Resident #56) reviewed for indwelling urinary catheters. The facility failed to ensure Resident #56's urinary (foley) catheter was properly secured to his leg. This failure could place residents with urinary catheters at risk for damage to the bladder, penis, or urethra (a hollow tube that lets urine leave your body), dislodging of the catheter, and urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' who used anticoagulant medications were adequately monitored and free from unnecessary drugs for 2 of 5 residents (Resident #11 and Resident #58) reviewed for unnecessary medications. 1. The facility failed to monitor Resident #11 for side effects of Eliquis (an anticoagulant medication-blood thinner). 2. The facility did not monitor Resident #58 for side effects/adverse reactions for the use of anticoagulant (blood-thinning) medications. This failure could place residents at risk of bruising and bleeding.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free from a medication error rate of 5 percent or greater. The facility had a medication error rate of 6.67 %, based on 2 errors out of 30 opportunities, which involved 2 of 7 residents (Resident #60 and #30) reviewed for medication administration. 1. The facility failed to ensure LVN Q administered insulin correctly for Resident #60. 2. The facility failed to ensure LVN O administered insulin correctly for Resident #30. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents were free of significant medication errors for 2 of 6 residents reviewed for medication pass. (Resident #60 and Resident #30) 1. The facility failed to ensure LVN Q administered insulin correctly for Resident #60. 2. The facility failed to ensure LVN O administered insulin correctly for Resident #30 These failures could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of the 5 medication carts reviewed for medications storage. (Hall C) The facility failed to ensure Resident #5 and Resident #52's Humalog (fast-acting insulin to control high blood sugar) insulin were taken off the cart after the opening date had expired on Hall C's nurse cart. The facility failed to ensure Resident # 17 Breo Ellipta inhaler (medication used to prevent and decrease symptoms of wheezing and trouble breathing), was dated when opened on Hall C's nurse cart. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 20 residents (Resident #45) reviewed for laboratory services. The facility failed to ensure Resident #45's CBC (complete blood count blood test that measures the number of different types of red blood cells, white blood cells, and platelets), CMP (comprehensive metabolic panel blood test that is used to get a broad assessment of your overall physical health it can check several body functions and processes), ESR (Erythrocyte Sedimentation Rate- blood test that can show if you have inflammation in your body), and CRP (C-reactive protein- blood test that measures the level of a protein called C-reactive protein in the blood which increases when there is inflammation in the body) were drawn on 01/01/2024 and 01/08/2024. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to accommodate residents' food preferences for 1 of 4 residents (Resident #27) reviewed for preference. The facility failed to honor Resident #27's preference for no toast. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for existing staff, consistent with their expected roles for 2 of 21 employees (Dietician and LVN P) reviewed for required annual trainings. The facility failed to ensure the Dietician and LVN P received required restraint and HIV training annually. This failure could place residents at risk for inappropriate restraints and exposure to HIV.

Inspectors wroteBased on interview and record review, the facility failed to ensure that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers for 1 (Resident #1) of 1 resident reviewed for an in-house acquired pressure ulcer. The facility failed to ensure Resident #1 did not develop two avoidable facility acquired pressure injuries. The facility failed to initiate new orders for Resident #1. The facility failed to remove the immoblizer boot (a medical device worn during treatment and recovery of a variety of foot injuries - it is a form of immoblizing and weight bearing for injuries to foot areas) and accurately assess Resident #1's right lower leg during weekly skin assessments from 10/02/2023 - 10/18/2023. The non-compliance was identified as past non-compliance. The Immediate Jeopardy began on 10/02/2023 and ended on 10/26/2023. [...]