Rayburn Health Care & Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 2 medication carts (Medication Cart L and Medication Cart R) reviewed for labeling and storage. The facility failed to ensure Medication Aide A's (the only assigned staff for medication administration on the secure unit.) assigned medication cart's (Medication cart L, and Medication cart R) were kept locked and under direct observation where 13 residents and unauthorized staff could not access it when left on the hall of the secure unit for four minutes. This failure could place residents at risk of gaining access to and swallowing medications not prescribed for them.

Inspectors wroteBased on observation, interviews and record review, the facility failed to review and revise resident's comprehensive care plans based on changing goals, preferences and needs of the resident and in response to current interventions for 4 of 18 (Residents #1, #3, #35, and #41) residents reviewed for comprehensive care plans.1. The facility failed to ensure Resident #1's care plan was updated to indicate Resident #1 had a diet change of Low Concentrated Sweets, pureed textures with nectar/mildly thick consistency on 06/15/2025.2. The facility failed to ensure Resident #3's care plan was updated for her change from Full Code to DNR on 01/07/26.3. The facility failed to ensure Resident #35's care plan was updated to indicate d Resident #35 had oxygen on 01/11/26. 4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 Medication Storage room and 1 of 3 medication carts (Hall 400 medication cart) reviewed for pharmacy services. The facility failed to remove expired normal saline (sodium chloride) vials that expired on 04/2025 from Hall 400 medication cart. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were completely documented for 2 of 7 residents reviewed for complete medical records. (Residents # and #35)* The facility did not have orders for Residents #4 to reside on the secured unit. * The facility did not have orders for Resident #35 having oxygen This failure could place residents at risk of restraint, isolation, and not receiving the care needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 4 of 12 residents (Residents #8, #28, #35 and #39) observed for Infection Control. 1. The facility failed to implement EBP for Resident #8 during a G-tube dressing change on 01/20/2026.2. The facility failed to immediately implement Contact Isolation Precautions for Resident #28 when she admitted on [DATE], for MRSA of a wound.3. The facility failed to ensure the enhanced barrier precaution signage was posted on Resident #39's door. 4. The facility failed to ensure Resident #35's oxygen tubing was labeled and dated and the nasal cannula was not laying on the floor. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to formulate an advance directive was provided for 1 of 2 residents reviewed for resident rights. (Resident #26) * The facility did not have a valid Out of Hospital-Do Not Resuscitate (OOH-DNR) for Resident #26. This failure could place residents at risk of lifesaving procedures being performed against their wishes resulting in bruising, broken ribs, electrical shocking of the heart, having a tube placed in the throat and provided artificial breathing methods, and possibly being brought back to life in an unaware and unresponsive state.

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 of care for 1 of 7 residents (Resident #39) reviewed for new admissions. The facility did not accurately complete a baseline care plan within 48 hours of admission for Resident #39 to address EBP (Enhanced Barrier Precautions) related to hemodialysis (a procedure that acts as an artificial kidney to filter waste products, toxins, and excess fluid from the blood when the kidneys are no longer functioning properly). This failure could lead to residents not receiving necessary care and decreased quality of life. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for 1 of 1 kitchen reviewed for food service safety. The facility failed to close, label and date a box of biscuits and bag of tater tots in freezer #4, to prevent exposure to air. This failure placed residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for 8 at least consecutive hours 7 days a week (140 days) and have a DON licensed in her state of residency (since [DATE]) reviewed for sufficient staffing. The facility failed to ensure they had a full time DON licensed in Texas and failed to ensure there was an RN for 8 consecutive hours 7 days a week. These failures could place residents at risk of lack of nursing oversight and a higher level of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a clean and comfortable environment for 1 of 1 secured unit reviewed for environmental concerns. The facility failed to ensure that floors were clean and devoid of dirt and debris in the secured unit. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received an accurate assessment, reflective of the resident's status for 3 of 19 residents reviewed for accuracy of assessments. (Resident #s 21, 23 and 27) The facility did not accurately complete the MDS assessment to indicate Resident #21 did not have a restraint. The facility did not accurately complete the MDS assessment to indicate Resident #23 did not have a restraint. The facility did not accurately complete the MDS assessment to indicate Resident #27 did not have a restraint. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on 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 meet professional standards of quality care within 48 hours of a resident's admission including the minimum healthcare information necessary to properly care for 1 of 3 residents reviewed for new admissions (Resident #267). The facility failed to develop and implement a baseline care plan within 48 hours of admission for Resident #267. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to include measurable objectives and timeframe to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 19 residents reviewed for care plans. (Resident #'s 16). The facility did not follow the physician orders for Resident #16's LCS (low concentrated sweet) diet. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards for 1 of 4 Halls (Hall 200). There was lighter fluid stored closer than 20 feet to the outside of Hall 200. This failure could place the residents at risk of accidents.

Inspectors wroteBased on interview, and record review, the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 resident reviewed for pain management. (Resident #32) The facility failed to ensure Resident #32 had effective pain management by failing to have routine pain medication available. This failure could place residents at risk for increased pain and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents reviewed for medications. (Resident #32) The facility failed to ensure: Resident #32 missed 3 doses of hydrocodone 10/325mg (12:00 p.m., 4:00 p.m., and 8:00 p.m. doses) on 10/20/2024. These failures could cause increased pain and decreased quality of life Resident #32

Inspectors wroteBased on record review and interview the facility failed to ensure the arbitration agreement contained all the required elements for 1 of 1 facility reviewed for Arbitration Agreements. The facility did not ensure the arbitration agreement contained the required elements: *Failed to provide the right to rescind in 30 calendar days of signing This failure could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues.

Inspectors wroteBased on record review and interview the facility failed to ensure the Arbitration Agreement included the provision of a neutral arbitrator and a convenient venue for 1 of 1 facility reviewed for Arbitration Agreements . The facility failed to ensure the provision of a neutral arbitrator. The facility failed to ensure the Arbitration Agreement contained a section indicating the provision of a convenient venue. These failures could place the residents or the residents' responsible parties in binding agreements not fully understood, have a loss of their legal rights, and cause negative psychological issues.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 4 of 21 residents reviewed for restraint use (Resident #56, Resident #12, Resident #23, and Resident #27). The facility failed to ensure Resident #56 was free from physical restraints in the form of a merry walker/merry chair (a wheeled walker with a seat used for use by individuals with balance or walking disabilities) and a bed alarm (devices that contain sensors that trigger an alarm or warning light when they detect a change in pressure). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who require dialysis receive such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of one resident (Resident #22) reviewed for dialysis services. The facility failed to develop a process to communicate with the dialysis facility, where Resident #22 received hemodialysis services. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their established smoking policy for 3 or 24 (Residents #37, #58, and #14) residents reviewed for smoking. The facility failed to ensure Residents #37, #58 and #14 did not have smoking supplies at their bedside and in their possession . This failure could place residents at risk for injury, harm, and impairment or death.

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 bathing were provided for 1 of 16 residents reviewed for ADLs (Residents # 60). The facility did not provide scheduled showers, grooming and nail care for Resident #60. The failure could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to obtain routine dental services to meet the need of each resident for 1 of 23 residents reviewed for dental services. (Resident #48) The facility failed to provide routine and follow up dental services for Resident #48, who had missing and decayed teeth, and recent tooth infection/abscess. This failure could place the residents at risk for not receiving care and services to prevent further decline, dental pain, and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 8 resident personal refrigerators reviewed for food safety (Resident #60). The facility failed to ensure the refrigerator for Resident #60 did not contain expired orange juice. This failure could place resident at risk for food borne illnesses.