Red Oak Health and Rehabilitation Center

Inspectors wroteBased on interviews and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change of condition for 1 of 6 (Resident #1) residents reviewed for comprehensive assessments. The facility did not complete a significant change MDS for Resident #1 after he was transferred to another hospice services on 06/04/2026. This failure could place residents at risk of not having their individual needs met when a significant change in condition occurs.

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 safety in the facility's only kitchen reviewed for dietary services. The facility failed to ensure food was safely stored, labeled, and dated in the walk-in refrigerator on 03/11/2026. The facility failed to ensure food was safely stored, labeled, and dated in the kitchen pantry on 03/11/2026. These failures have the potential to affect the residents who ate food from the facility's kitchen, placing them at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 6 residents (Resident #111) reviewed for medications storage. During medications administration, MA A left Resident #111 without ensuring medications were swallowed. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1of 2 medication storage rooms (room located by hall 400) and 2 of 2 medication carts (Hall 400 Medication Aide's Cart and Hall 400 Nurse's Cart). 1. The facility failed to ensure expired medication administration supplies and Covid test were removed from 1 of 2 medication storage rooms (room located by hall 400). 2. The facility failed to follow policy and date opened medications on 2 of 2 medication carts (Hall 400 Medication Aide's Cart and Hall 400 Nurse's Cart). These failures could place residents at risk for ineffective treatments, incorrect diagnosis, cause a Peripheral IV Catheter to need replacement and or allow Covid infections to spread.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for five (5) staff reviewed for qualified dietary staff. The facility failed to ensure that dietary DS B, DS D, DS E, DS G, and DS H obtained and/or maintained their Texas Food Handler Certificates. This failure practice could place residents who ate from the facility's only kitchen at risk of foodborne illness and not having their nutritional needs met and at risk of contracting foodborne illnesses. Finding Include: [...]

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 safety for one (1) of one (1) facility kitchen and one (1) of two (2) nourishment rooms reviewed for food safety (Station 2 Med Room). 1. The facility failed to ensure food items in the kitchen refrigerator were dated and labeled. 2. The facility failed to ensure the ice machine in the kitchen and in one (1) of two (2) nourishment rooms were cleaned and free of mold, mildew and slime. 3. The facility failed to discard a dented can. 4. The facility failed to discard food items past their expiration date. 5. The facility failed to maintain accurate freezer temperature logs for the freezer in the kitchen and one (1) of two (2) freezers in the nourishment rooms (Station 2 Med Room). 6. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure comprehensive care plans were reviewed and revised by the interdisciplinary team including both the comprehensive and quarterly review assessments for 1 of 6 residents (Resident #20) reviewed for care plans. The facility failed to ensure Resident #20's comprehensive care plan was revised to reflect the need for and the use of a fall mat. This failure could place the residents at risk of not receiving the appropriate care and services to maintain their highest practical well-being.

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 1 of 6 residents (Resident #36) reviewed for infection control. CNA A failed to wash or sanitize her hands while going from a dirty to clean surface while performing incontinent care on 01/14/25 at 1:30 PM for Resident #36. This deficient practice could place residents at risk for cross contamination and the spread of infection.

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 8 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure MA A secured Resident 1's medication when she left Resident #1's medications on her bedside table for her to self-administer and did not ensure the resident took her medication. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received services in the facility with reasonable accommodations of resident's needs and preferences except when to do so would endanger the health and safety of the resident or other residents for 2 of 9 residents (Residents #1 and #2) reviewed for resident rights. The facility failed to ensure Resident #1 and #2's call lights were within reach on 07/17/24. This failure could place residents at risk of needs not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to have all residents receive treatment and care in accordance with professional standards of practice, the comprehensive care plan, for 1 of 7 (Resident # 1) residents reviewed for care. The facility failed to provide a clean comfortable environment for Resident #1 by allowing him to lay in a soiled bed . This failure could place residents at risk for further skin integrity impairment, untreated medical issues, and diminished quality of care.

Inspectors wroteBased on interviews and record review the facility failed to provide adequate supervision and to prevent accidents for one resident (Resident #1) of four reviewed for accidents and hazards. The facility failed to supervise Resident #1 when she was sitting at the nurse's station, which resulted in a fall with injuries on [DATE]. This failure placed residents at risk of accidents or falls resulting in injuries, pain, and hospitalization.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse or neglect, including injuries of unknown source, were e reported immediately, or not later than 24 hours to other officials (including to the State Survey Agency) in accordance with State law through established procedures for one (1) resident (Resident #1) of seven (7) residents reviewed for abuse and neglect. The facility failed to report Resident #1's fall on [DATE], which resulted in a head injury, in a timely manner to the State. This failure could place residents at risk for abuse, neglect, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute food in accordance with professional standards for food service safety for one of one kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary [NAME] E and Dietary Aide F wore a hair restraint while in the kitchen. 2. The facility failed to properly label and date leftover food in one of one walk-in refrigerator. 3. The facility failed to ensure Dietary [NAME] E properly sanitized her hands between tasks. These failures could place residents who were served from the kitchen at risk for health complications, foodborne illnesses, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good grooming and personal hygiene for four of twenty-one (Resident # 41, Resident #45, Resident #50, and Resident #51) reviewed for ADL's. The facility failed to ensure Resident # 41's, Resident # 45's, Resident # 50's, and Resident # 51's fingernails were trimmed and cleaned. These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life.

Inspectors wroteBased on observations, interview and record review, the facility failed to respect the residents' right to personal privacy of medical records and medical treatment for 3 of 10 Residents (Residents #70, #94 and #46) reviewed for privacy. The facility failed to ensure LVN C protected confidential resident healthcare information for Residents #70, #94, and #46 by leaving the information uncovered on a yellow paper tablet on top of her medication cart. This failure could place residents at risk of personal information being exposed to unauthorized persons, loss of dignity, and low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to serve food that was palatable, attractive, and at a safe and appetizing temperature for 1 of (1) kitchen reviewed. The facility failed to ensure meals were served hot and at a safe appetizing temperature. This failure could place residents at risk of reduced quality of life, weight loss, and food-borne illness.