Richardson Nursing and Rehabilitation

Inspectors wroteBased on observations, interviews, 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 included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to update Resident #1's care plan related to her recent fall. These failures could place the residents at risk of not receiving the necessary care and services.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the residents environment remained free of accidents and hazards for all residents reviewed for hazards. The facility failed to ensure that a gas-powered lawn [NAME] containing active liquid fuel was not stored inside a vacant area in the 2400 hall currently designated as a temporary storage area within an active renovation zone. This failure placed residents, visitors and staff at risk of harm and injury in the event of anfire.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure receiving 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 4 of 9 residents (Residents #2, #3, #4 and #5) reviewed for the resident rights. The facility failed to ensure the call light system in Resident #2's room was in a position that was accessible to the resident. The facility failed to ensure the call light system in Resident #3's room was in a position that was accessible to the resident. The facility failed to ensure the call light system in Resident #4's room was in a position that was accessible to the resident. The facility failed to ensure the call light system in Resident #5's room was in a position that was accessible to the resident. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 8 residents (Resident s#5 and #6) reviewed for respiratory care. The facility failed to ensure Resident #5's nasal cannula connected to the oxygen concentrator (medical device that extracts oxygen from room air by filtering out or separating the nitrogen from the oxygen) was properly stored. The facility failed to ensure Resident #6's nasal cannula connected to the oxygen concentrator was properly stored. These failures could place the residents at risk of respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 2 of 9 residents (Resident #1 and #7) reviewed for dignity. Resident #1 was observed lying in bed and his catheter bag could be observed hanging from his bed without a privacy cover. Resident #7 was observed sitting on his bed and his catheter bag could be observed laying on the floor without a privacy cover. These deficient practices could place residents at risk of not feeling as if they were being treated with dignity, privacy, and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 8 (Residents #8) reviewed for medication storage. The facility failed to ensure that Resident #8 did not have zinc oxide in his room. The failure could place residents at risk of accidental overdose, misuse of medications, and possible adverse reactions.

Inspectors wroteBased on observation, interview and record review the facility failed to have complete and accurately documented medical records for one of eight Resident (Resident #9) whose clinical record was reviewed for accuracy. The facility failed to record on the TAR wound care provided to the resident on 04/17/26, 04/18/26, 04/19/26, 04/20/26, and 04/21/26. This failure could affect all residents at risk for inaccurate or incomplete clinical records and place residents at risk for her wound care not being done as ordered.

Inspectors wroteBased on observations, interviews, 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 of eight (resident #7) residing on two of four halls (Hall 100 and 200) reviewed for infection control. The facility failed to ensure personal items were not stored on the medication carts located on hall 100 The facility failed to ensure that CNA M had on PPE when providing high contact care for Resident #7. This failure could place the residents at risk of an infection during medication administration and care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure coordination of care with the Hospice agency, specific to each patient, for 1 (Resident #1) of 5 residents reviewed for hospice services. Resident #1 was sent to the hospital on [DATE] after her g-tube was dislodged and needed to be replaced. The facility failed to report this hospital transfer to the hospice agency. This failure could affect residents who received Hospice services by placing them at risk for services and treatments not being coordinated.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident had a right to confidentiality of his or her personal and medical records for five of eighteen residents (Residents #3, #5, #61, #73, and #79) reviewed for privacy and confidentiality. 1. The facility failed to ensure MA G secured Residents #3, #61, #73, and #79's medical information before leaving her cart on 03/11/2026. 2. The facility failed to provide privacy during Resident #5's transfer via mechanical lift on 03/10/2026. These failures could place the residents at risk of not having their personal privacy maintained while treatment and care were provided, which could result in the residents feeling uncomfortable during treatment and having their personal and medical record exposed to unauthorized individuals.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 11 of 20 Resident rooms (room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11), and two of the six carpeted floor halls (2100 and 2500) observed for cleanliness. The facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for 1 of 7 (Resident #15) reviewed for misappropriation of property. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, #9, #10, and #11 were thoroughly cleaned and sanitized. The facility failed to ensure the carpeted floor halls on 2100 and 2500 were thoroughly cleaned and sanitized. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for three of eight residents (Residents #2, #5, and Resident #19) reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #2's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was admitted to hospice. 2. The facility failed to ensure Resident #5's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was on oxygen therapy. 3. The facility failed to ensure Resident #19's Comprehensive MDS assessment dated [DATE] accurately reflected that the resident was using an AVAPS. These failures could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health.

Inspectors wroteBased on observations, interviews, 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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for four of twelve residents (Residents #14, #15, #19, and #29) reviewed for care plans. 1. The facility failed to ensure Resident #14 was care planned for oxygen therapy. 2. The facility failed to ensure Resident #15 was care planned for congestive heart failure. 3. The facility failed to ensure Resident #19 was care planned for her AVAPS. 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for ten of eleven residents (Residents #4, #7, #10, #11, #24, #31, #34, #74, #91, and #96) and for two of four LVNs (LVN B and LVN I) reviewed for accident hazards.1. The facility failed to ensure Resident #31 had her fall prevention interventions which included a fall mat to each side of bed every shift for safety. 2. The facility failed to ensure Residents #4, #10, #11, #24, #34, #74, #91, and #96 were properly supervised while smoking in the smoking area of the facility and that Resident #4, #10, #24, #34, #74, #91, and #96 had quarterly smoking assessments completed.3. The facility failed to ensure that LVN B did not leave a container of germicidal wipes on top of her cart unattended on 03/10/2026. 4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of twelve residents (Residents #5, #6 and #15) reviewed for respiratory care. 1. The facility failed to ensure Resident #5's nasal cannula was stored properly when not in use on 03/10/2026. 2. The facility failed to ensure Resident #6's nasal cannula was stored properly when not in use on 03/10/2026. 3. The facility failed to ensure Resident #15's breathing mask was stored properly when not in use on 03/10/2026. These failures could place residents at risk of respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to assess the resident for appropriateness and review the risks and benefits of grab/assist bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative and obtain informed consent prior to installation for 4 (Resident #1, Resident #13, Resident #76, Resident #91) of 7 resident rooms observed and reviewed for grab/assist bars. The facility failed to have evidence of informed consents for Resident #1, Resident #13, Resident #76, and Resident #91 for grab/enabler bars to be placed on the bed. The facility failed to have evidence of assessments for Resident #1, Resident #13, Resident #76 and Resident #91, for risk of entrapment and ability to safely use the grab/enabler bars. [...]

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. The facility failed to ensure food items in the refrigerator were dated, labeled, and sealed appropriately. The facility failed to ensure the ice machine was thoroughly cleaned and sanitized. The facility failed to ensure the ice scoop holder was thoroughly cleaned and sanitized. The facility failed to ensure the ice chest on the 2500-hall was thoroughly cleaned and sanitized. The facility failed to ensure the tea dispenser was covered with a lid. The facility failed to ensure the rinse temperature on the dishwasher was at the manufacturers required operating temperature of 180 degrees. [...]

Inspectors wroteBased 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 three of fifteen residents (Residents #5, #29, and Resident #38) reviewed for infection control. 1. The facility failed to ensure CNA D and CNA E performed hand hygiene before transferring Resident #5 on 03/10/2026. 2. The facility failed to ensure LVN B wore a gown while administering Resident #29's medication via g-tube on 03/10/2026. 3. The facility failed to ensure CNA F performed hand hygiene and changed her gloves after touching the soiled draw sheet during Resident #38's incontinent care on 03/10/2026. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure that the transfer or discharge was documented in the resident's medical record for one (Resident #105) of three residents reviewed for transfers and discharges. The facility failed to accurately document Resident #105's discharge on [DATE]. This failure could prevent the resident or their caregivers from receiving necessary information about the resident's support needed for further care.

Inspectors wroteBased on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 2 of 11 residents (Resident #1 and Resident #65) reviewed for MDS transmission. Residents #1 and #65 Quarterly MDS assessments were completed but not transmitted within 14 days of completion. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 7 residents reviewed for wound care (Resident #14). The facility failed to follow the facility's wound cleaning protocol for Resident #14's right heel dressing change. This failure put Resident #14 at risk of not receiving necessary treatments and a worsening of their wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 7 residents reviewed for pressure injuries. (Resident #31) The facility failed to apply foam boots to bilateral heel to prevent pressure ulcer for Resident #31. This failure can place the residents at risk for new development pressure injuries and could result in a decline in health.

Inspectors wroteBased 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 infection and to restore continence to the extent possible for one of five residents (Resident #44) reviewed for catheter care. The facility failed to ensure Resident #14 had orders for her catheter. This failure could place residents with catheter at risk for urinary tract infection and other catheter- associated complications.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 out of 7 residents (Resident #31) reviewed for enteral feeding. Resident #31 was not provided with an abdominal binder for G-tube site protection as ordered. This failure could place residents with a G-tube at risk of increased risk for infection and complications.

Inspectors wroteBased on interviews, and record reviews 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 8 residents (Resident #39) reviewed for administration of all drugs. The facility failed to ensure Resident #39's morning medications were recorded on the resident's MAR once administered to the resident on 03/03/26. This failure could place residents at risk of receiving duplicate medication and being overly medicated.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for one of twelve residents (Resident #90) and one (Medication Aide's Cart) of three carts reviewed for medication storage. 1. The facility failed to ensure Resident #90 did not have any medications inside her room on 03/10/2026. 2. The facility failed to ensure probiotics were refrigerated as per instruction of the manufacturer on 03/11/2026. These failures could place the residents at risk of accidental overdose, misuse of medications, not receiving the medication's full therapeutic benefits, and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for one (Resident #3) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #3's room was in a position that was accessible to the resident on 06/17/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review, the facility failed to secure confidential and personal medical records for one (Residents #4) of one resident reviewed for privacy and confidentiality. The facility failed to ensure LVN A closed, locked, or minimized her laptop's monitor when she left her cart on 06/17/2025 and Resident #4's medical information was visible. This failure could place the residents at risk of exposure of their personal and medical information to unauthorized individuals.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide appropriate treatment and services to prevent complications of enteral feeding for one (Resident #3) of one resident reviewed for feeding tube (a way of providing nutrition directly to the stomach). The facility failed to ensure that Resident #3's, who had a g-tube (gastrostomy tube: a tube inserted through the abdomen that delivers nutrition directly to the stomach), head of the bed was raised on 06/17/2025. This failure could place residents with g-tubes at risk for reflux and aspiration.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for six (Residents #1 and #2) of six residents reviewed for respiratory care. 1. The facility failed to ensure Resident #1's breathing mask (used to receive medications by breathing in mist through nose and mouth) was properly stored when not in use on 06/17/2025. 2. The facility failed to ensure an Oxygen in Use sign was placed outside of Resident #2's room when she was admitted to the facility on [DATE]. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored properly in locked compartments for one medication (wound cleanser solution) of one medication reviewed for storage of drugs and biologicals. The facility failed to ensure that the wound cleanser solution was not left inside Resident #3's bedside. This failure could place the residents at risk of accidental consumption or misuse of medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) to the maximum extent practicable for 1 (Resident #1) of 2 residents reviewed for PASRR. The facility failed to follow up with more information request after receiving notification from PASRR between 11/25/2024 and 12/01/2024, which led to a denial of physical therapy services for Resident #1. This failure could place all residents identified as mentally, intellectually and/or developmentally disabled at risk of not receiving specialized services and equipment to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 4 of 6 resident rooms (room [ROOM NUMBER], #2, #3, and #4) and all the facility hall floors reviewed for environment. 1. The facility failed to ensure resident rooms #1, #2, #3, and #4 were thoroughly cleaned and sanitized. 2. The facility failed to ensure the facility hallway floors were cleaned and sanitized. These deficient practices could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to be treated with respect and dignity for 1 of 4 residents (Resident #1) reviewed for dignity. The facility failed to ensure staff properly fed Resident #1 breakfast, while she was lying in bed. This deficient practice could place the resident at risk of not feeling as if they were being treated with dignity and respect while being fed.

Inspectors wroteBased on observation, interview, and record review the facility failed to treat residents with respect and dignity for one (Resident #1) of seven residents reviewed for resident rights. The facility failed to ensure LVN A did not stand over Resident #1 while assisting the resident with her meal in the dining room on 01/15/25. This failure could affect residents who require assistance with activities of daily living and place them at risk of feeling rushed to eat or not interested in eating, which could result in weight loss and decreased psycho-social well-being of anguish or frustration.

Inspectors wroteBased 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 two of eight residents (Resident #77 and Resident #199) reviewed for Infection Control. 1. The facility failed to ensure CNA E changed her gloves and performed hand hygiene while providing incontinent care to Resident #77 on 12/10/2024. 2. The facility failed to ensure CNA D changed her gloves and performed hand hygiene while providing incontinent care to Resident #199 on 12/10/2024. 3. The facility failed to ensure that RN B would not bring the whole container of test strips used for checking blood sugar inside Resident #77's room on 12/11/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 of 12 residents (Resident #49 and Resident #77) reviewed for Respiratory Care. 1. The facility failed to ensure Resident #49 had an order for oxygen administration. 2. The facility failed to ensure Resident #77's BiPAP (bilevel positive airway pressure - normalizes breathing by delivering pressurized air into the upper airway leading into the lungs) mask was properly stored. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased observation, interview, and record review, the facility failed to ensure that one of two (Resident #86) residents were provided medications and/or biologicals and pharmaceutical services to meet their needs. The facility failed to ensure LPN C flushed the g-tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) before and after each medication on 12/10/2024. This failure could place the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observation and interviews, the facility failed to maintain all patient care equipment in the laundry room in safe operating condition. The facility failed to ensure one (the washer located near the back wall) of two washing machines in the laundry room was maintained. These failures could place residents at risk of contamination and improper laundering of items. Findings Included: An observation and interview 12/11/24 at 08:22 AM revealed sudsy water running from the door of a front-loading washer in the laundry room onto the floor below. The drain was directly in front of the washer. A trash bag was twisted and looped through the handle of the washer door and tied to a handle on the washer panel, just above the door. There was lime buildup along the front of the washer below the door and on the side of the washer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan described the services furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #1) of four residents reviewed for Comprehensive Care Plans. The facility failed to devise and implement any Comprehensive Care Plan goals and/or interventions for Resident #1's documented wandering, exit seeking, and/or elopement behavior on 07/16/2024 to prevent an incident of elopement by Resident #1 on 08/27/2024. Additionally, Resident #1 had a documented history of physical aggression on 07/16/2024 at 9:20 PM that necessitated the relocation of his roommate but was not updated on his Comprehensive Care Plan. An Immediate Jeopardy (IJ) was identified and presented to the Administrator on 08/28/2024 at 4:10 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards for one (Resident #1) of four residents reviewed for elopement behavior. Resident #1 had a documented history of wandering and/or exit seeking behavior on 07/16/2024. The facility failed to provide adequate supervision to Resident #1 who had a history of exit seeking behavior. The facility did not accurately re-assess his elopment risk assessment, monitor, or update the residents care plan after the incident. On 08/27/2024 around approximately 6:00 AM the resident was located by the facility's SLP outside the facility beyond the Therapy Services door. An Immediate Jeopardy (IJ) was identified and presented to the Administrator on 08/28/2024 at 4:10 PM. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving neglect, are reported immediately, but not later than 2 hours after the allegation is made, to HHSC for 1 (Resident #1) of 6residents reviewed for reporting. The facility's Abuse Coordinator failed to report to HHSC Resident #1's elopement incident that occurred on 08/27/2024. This failure could place residents at risk of continued neglect. Findings Included: Record Review of Resident #1's Face Sheet, dated 08/27/2024 revealed he was a [AGE] year-old male admitted to the facility 11/03/2019. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving neglect were investigated following reporting any alleged allegations to HHSC for 1 (Resident #1) of 6 residents reviewed for investigation. The facility's Abuse Coordinator failed to investigate to HHSC Resident #1's elopement incident that occurred on 08/27/2024. This failure could place residents at risk of abuse, neglect, and/or exploitation. Findings Included: Record Review of Resident #1's Face Sheet, dated 08/27/2024 revealed he was a [AGE] year-old male admitted to the facility 11/03/2019. Relevant diagnoses included dementia, major depressive disorder, generalized anxiety disorder, weakness, unsteadiness on feet, blindness in one eye, and macular degeneration (vision impairments.) Record review of Resident #1's Progress Note by LPN Y, dated 08/27/2024, revealed: [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for one (Resident #1) of six residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1's Quarterly MDS assessment dated [DATE] accurately reflected that Resident #1 visual impairments. This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for one of one facility reviewed for environment. 1. The facility failed to ensure the foundation, walls, and ceiling were in good repair in the hallway to the right of the secretary's desk. 2. The facility failed to ensure the carpets were clean and stain free throughout the facility. These failures could affect all residents, resulting in falls and cross contamination which could lead to a decline in the resident's health and physical functioning.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #50) of one resident reviewed for respiratory/tracheostomy care. The facility failed to ensure Resident #50's tracheostomy shield was changed per week per physician order. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, clean, comfortable, and homelike environment for 15 of 30 resident rooms (Resident # 2, #3, #9, #12, #14, #16, #20, #21, #26 #28, #29, #38, #55, #94, and #200) , the handrails and the carpet throughout the facility observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that resident rooms on multiple halls (100 & 200 halls) were free of diirt and stains on the floors, walls, mini friidges and air-condition units. The facility failed to ensure handrails on all resident halls were free of dirt particles, stains, and dust. These failures could place residents at risk of infections and living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 6 residents (Residents #35, #38, and #84) reviewed for ADLs care provided to dependent residents. The facility failed to ensure Residents #35, #38, and #84 received baths or showers consistently based on records reviewed from 9/1/2023 - 10/18/2023 referencing resident showers. This failure could place residents at risk of not receiving necessary services to maintain good personal hygiene, skin integrity, or decreased self- esteem. Findings Included: Record review of Resident #35's Face Sheet, dated 10/19/23, revealed she was a 75 -year-old female admitted on [DATE]. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that 4 (Resident #7, Resident 18, Resident 28, and Resident 31) of 10 residents were provided medications and/or biologicals and pharmaceutical services to meet the needs of the residents. The facility failed to ensure CMA Y re-ordered medications on a timely manner for Resident #7 (Eliquis 2.5 mg). The facility failed to ensure CMA Y re-ordered medications on a timely manner for Resident #18 (Sertraline HCL 50 mg). The facility failed to ensure CMA Y re-ordered medications on a timely manner for Resident #28 (Tramadol 50 mg). The facility failed to ensure CMA Y re-ordered medications on a timely manner for Resident #31 (Metoprolol Tartrate 50 mg, Buspirone HCL 10 mg, Gabapentin 100 mg, Finasteride 5 mg, and Amlodipine Besylate 5 mg). [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen reviewed for kitchen sanitation. The facility failed to ensure foods in the facility's dry storage area, refrigerators, and freezer were stored, labeled, and dated. The facility failed to ensure expired foods were discarded. The facility failed to ensure kitchen equipment were clean and sanitary. These failures could place residents at risk for cross contamination and other illnesses.

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat 1 of 6 (Resident #38) residents reviewed with dignity and respect. The facility failed to ensure Resident #38's room was clean and sanitized, the facility failed to ensure the resident received activities of daily living care, and the facility failed to ensure the resident was free of any hazards. This failure could prevent residents from attaining or maintaining the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care.

Inspectors wroteBased on interviews and record review, the facility failed to manage the resident's funds for 1 of 1 resident (Resident #196) reviewed for Protection and Management of Personal Funds. The facility failed to manage the transfer of the Resident 196's Trust fund from the resident's prior living facility and the failed to manage the transfer of his Social Security funds from his prior living facility. This failure could place resident at risk of not being able or allowed to handle their personal affairs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents had physician's orders for the resident's immediate care for two (Resident #41 and Resident #53) of six residents reviewed for admission orders. The facility failed to provide physician's orders for heel protectors as preventive measure for Resident #41 at the time of admission. The facility failed to provide physician's orders for oxygen supplement for Resident #53 at the time of admission. These failures could place the resident at risk of not receiving necessary care and services upon admission that could result to worsen condition.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident received an accurate assessment, reflective of the resident's status for 1 of 8 residents (Resident #83) reviewed for Accuracy of Assessments. The facility failed to ensure Resident #83's MDS accurately reflected Section I-Active diagnosis included I1700. Multidrug-Resistant Organism (MDRO). The resident had candida auris (highly contagious illness). This failure could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 4 of 8 sampled residents (Resident #41, Resident #50, Resident #53, and Resident #83) reviewed for Care Plans. The facility failed to ensure Resident #41's was care planned for heel protectors as a preventive measure. The facility failed to ensure Resident #50's was care planned for Hospice care. The facility failed to ensure Resident #53's was care planned for oxygen. The facility failed to ensure Resident #83's Care Plan reflected she was on contact precautions for candida auris (highly contagious infection). These failures could place residents at risk for not receiving care and services to meet their needs, diminished function of health, and regressions in their overall health.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for 1 (Resident #53) of 6 residents reviewed for revised Care Plan. The facility failed to ensure Resident #53's care plan was revised to reflect discontinued use of CPAP/BiPAP. This failure could place the resident at risk of needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, including but not limited to standards of practice that will meet each resident's physical, mental, and psychosocial needs for 2 of 6 residents (Resident #43 and #45) reviewed for quality of care. The facility failed to record Residents #43 and #45's weekly weight on a as scheduled, utilizing a consistent method, for residents diagnosed with excessive weight loss. This failure could place residents at risk of experiencing unobserved and untreated excessive 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 1 (Resident #5) of 3 residents observed for infection control. The facility failed to ensure CNA A changed her gloves and performed hand hygiene while providing incontinence care to Resident #5. This failure could place residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 resident (Resident #1) of 6 residents reviewed for pharmacy services. -The facility failed to ensure that Resident #1's prescribed Clotrimazole-Betamethasone was stored in a secured place. This failure could place all residents on the 2200 Hall at risk of drug diversion or misuse of medications.

Inspectors wroteBased on observation and interview, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for four (Resident #11, Resident #12, Resident #13, and Resident #14) of ten residents reviewed for call lights. The facility failed to ensure the call light systems in Resident #11's, #12's, #13's, and #14's rooms were in a position that was accessible to the residents. Findings Included: Review of Resident #11's Face Sheet dated 09/25/2023 reflected that resident was a [AGE] year-old female admitted on [DATE]. Relevant diagnoses included type 2 diabetes mellitus without complications, unspecified dementia, major depressive order, epileptic seizures related to external causes, and hemiplegia (paralysis of one side of the body) affecting right dominant side. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of three (2600 Hall Treatment Cart) treatment carts reviewed for medication storage. The facility failed to ensure the 2600 Hall Treatment Cart was locked when unattended. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm or drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for personal privacy. The Nurse practitoner and LPN A failed to provide privacy for Resident #1 during wound care and incontinent care. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to a lack of privacy during their care .

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 11 of 6 (Resident #2) residents' bathrooms reviewed for environment. The facility failed to ensure Resident #2's bathroom was clear of soiled linens This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.