River Hills Health and Rehabilitation Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 15 (Resident #1) residents in 1 of 1 dining room reviewed for residents rights. The facility failed to promote Resident #1's dignity during lunch when staff did not serve Resident #1 her meal tray with other residents at her table. This failure could affect all residents who eat in the dining room, by contributing to emotional distress and unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, or mistreatment, including misappropriation were reported immediately, but not later than 2 hours after allegation is made, if the events that cause the allegation involve abuse or results in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 or 4 residents (Resident #1, Resident #3) reviewed for reporting missing funds. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administration of all drugs and biologicals) for 1 of 1 resident (Resident #2) to meet the needs of the resident, in that: Resident #2's narcotic count log indicated Oxycodone 5mg medication was administered two times on 04/13/2026 without documentation in the MAR.This deficient practice could place residents at risk for injuries by not having an accurate record of medication administration available in the medical record.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with professional standards for 2 of 8 medication carts (100 Hall nurses medication cart and 100 Hall medication aide cart) reviewed for storage of drugs. The facility failed to ensure the carts for 100 Hall, for both the nurse medication cart and the medication aide cart, were locked and secured on 05/05/2026609 .This failure could place residents at risk of medication misuse, medication errors, drug diversion or harm due to accidental ingestion of unprescribed medications.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative(s) of discharge and the reasons for the move in writing and in a language and manner they understand, as soon as practicable for 1 of 4 residents (Resident #1) reviewed for discharges. The facility failed to ensure Resident #1 received written notice of discharge after he was emergently discharged on 1/10/2026. This failure could result in a violation of residents' rights and improper discharge.

Inspectors wroteBased on interview and record review, the facility to ensure the assessment accurately reflected the resident's status for 1 of 4 residents (Resident #1) reviewed for resident assessments. The facility failed to ensure Resident #1's discharge MDS accurately reflected the frequency of the resident's physically aggressive and wandering behaviors at the time of discharge. This failure could lead to improper oversight and care of residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure the person designated as the infection preventionist completed specialized training in infection prevention and control for the facility. The facility failed to ensure the DON, who was designated as the facility's Infection Preventionist had completed specialized training in infection prevention and control. This failure could place residents at risk for cross contamination and infection and ineffective infection surveillance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 3 residents (Residents #1 and #2) reviewed for accidents/hazards. The facility failed to ensure fall mats were in place while Residents #1 and #2 were in bed on 9/16/2025. These failures could result in injury to residents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 4 (Residents #37, #63, #76, and #86) of 21 residents reviewed for care plans. 1. The facility failed to develop care plan interventions for Resident #37's hearing loss. 2. Resident #63's care plan had the wrong code status. 3. Resident #76's care plan had her oxygen liters wrong. 4. Resident #86's care plan had the wrong tube feeding formula. [...]

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 nutrition, grooming, and personal and oral hygiene for 1 of 6 residents (Resident #9) reviewed for personal hygiene. The facility failed to provide Resident #9 with 7 of 9 scheduled showers between 05/21/2025 and 06/11/2025. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 8 residents (Resident #18) reviewed for urinary catheters. The facility failed, for 10 consecutive days, to follow the physicians' order to flush Resident #18's urinary catheter twice a day. These failures could place residents at risk for a decline in their health status.

Inspectors wroteBased on record reviews and interviews the facility failed to ensure the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 1 of 1 facility's reviewed for nursing staffing. The facility failed to have the services of an RN on 5/31/2025 and on 6/1/2025. These failures could have placed residents at risk of not having the critical skills of a RN.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 2 medication storerooms and 3 of 10 medication carts reviewed for security and control, in that: 1. LVN L left the 100-hall medication cart unattended, unsupervised, and unlocked. 2. LVN Q left the 100-hall medication cart unattended, unsupervised, and unlocked. 3. LVN C left the medication room on the 100-200-hall unattended, unsupervised, and unlocked. These failures could place residents at risk of misappropriation of property, not receiving the therapeutic effects of medications, and or adverse effects of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 facility reviewed for food service safety, in that: 1. A fridge used to hold snacks and other food and drink items for residents was observed to contain an unlabeled and undated sandwich and a past best-by date gallon of milk. 2. A food storage bin had a scoop that was left in the bin. These failures could place residents who receive food and/or snacks from the facility at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 5 residents (Resident #13) reviewed for privacy, in that: The facility failed to ensure that MA (E) locked the computer after she walked away and left it unattended, which exposed Resident #13's morning medication list. This failure could place residents at risk of having their medical information exposed to others and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure. the resident has a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 4 community showers, 1 of 20 resident rooms, in that: 1. A community shower chair had brown substance at the bottom of seat. 2. 400 hall shower room was missing 1 tile. 3. room [ROOM NUMBER] door frame to bathroom was missing the frame on 1 side of the door frame. This failure could place residents at risk of lack of facility cleanliness and a homelike environment.

Inspectors wroteBased on the interview and record review, the facility failed to ensure that residents are free from chemical restraints related to PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order, for 1 of 3 residents (Resident #62) reviewed for chemical restraint, in that: The facility failed to ensure Resident #62 was prescribed a psychotropic drug for anxiety, no longer than 14 days PRN (as needed). This deficient practice could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and assistive devices to maintain hearing abilities for 1 of 8 residents (Resident #37) reviewed for hearing. The facility failed to ensure Resident #37 received appropriate services to assess for maintaining or improving hearing abilities. This failure could place residents at risk for unmet needs and diminished quality of life related to communication.

Inspectors wroteBased on observation, interview and record review failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 8 (#33) residents in the 400 halls, in that: Resident #33's fall matt was not in place. This failure could place residents at risk for injuries.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents were free from any significant medication errors, for 1 of 6 residents (Resident #9) reviewed for medication errors, in that: LVN C administered Resident #9's meropenem (an intravenous antibiotic used to treat a variety of bacterial infections) antibiotic intravenously at the wrong infusion rate and effectively administered the medication in half of the intended time, over 30 minutes instead of 1 hour. This failure could place residents at risk of not administering medications as prescribed and increasing adverse effects.

Inspectors wroteThe personal refrigerators in residents' Room # 203 A contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled.

Inspectors wroteBased on observations, interviews, and record reviews 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 reviewed for infection prevention protocols, in that: LVN KR administered Resident #9's antibiotic intravenously while placing the entire medication cart into Resident #9's room and then removing the cart, without sanitization, with intentions of continuing medication administration with peer residents. This failure could place residents at risk for harm by infections by cross contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to reside and receive 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 3 of 8 residents (Resident #6, #7 and #8) reviewed for reasonable accommodation of resident needs, in that:. 1. The facility failed to ensure Resident #6 had access to his call light which was wrapped up in a basket on his nightstand outside of the resident's reach. 2. The facility failed to ensure Resident #7 had access to his call light which was attached to his bed outside of the resident's reach. 3. The facility failed to ensure Resident #8 had access to his call light which was tucked inside of his closed nightstand drawer out of the resident's reach. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure that the MDS assessment accurately reflected the resident's status for 1 of 12 (Resident #3) whose MDS assessments were reviewed in that: Resident #3 had 1 of 2 falls inaccurately coded on the MDS assessment. This deficient practice could place residents at risk for inadequate care and services to meet their needs based on inaccurate MDS assessments.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that based on the comprehensive assessment of a residents, the residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 10 residents (Resident #1) reviewed for quality of care, in that: The facility failed to transcribe Resident #1's hospital order for insulin glargine on admission according to discharge instructions, and failed to administer the medication for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/7/25. The IJ template was provided to the facility on 2/7/25 at 5:01 PM. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmacological 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 10 residents (Resident #1) reviewed for pharmacy services. The facility failed to acquire, receive, dispense, and administer Resident #1's scheduled insulin 17u Insulin Glargine daily as ordered for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/07/2025. The IJ Template was provided to the facility on 2/07/2025 at 5:01 PM. While the IJ was removed on 2/08/2025, the facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective action. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from significant medication errors for 1 of 12 residents (Resident #1) reviewed for significant medication errors, in that: The facility failed to ensure Resident #1 was administered Insulin Glargine 17units daily for 6 days from 1/31/25-2/5/25. An IJ was identified on 2/07/2025. The IJ Template was provided to the facility on 2/07/2025 at 5:01 PM. The IJ was removed on 2/08/2025. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with potential for more than minimal harm that is not IJ, due to the need for the facility to evaluate the effectiveness of the corrective actions. This failure placed resident at risk for adverse side effects to include increase in blood glucose levels and life-threatening complication of Diabetic ketoacidosis.

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain laboratory services to meet the needs of its residents for 1 of 2 residents (Resident #2) reviewed for laboratory services, in that: The facility did not obtain a UA C&S (a medical test that combines a urinalysis with a culture and sensitivity test to diagnose and treat urinary tract infections) for Resident #2 as ordered by a physician. This deficient practice could place residents at risk for a delay in identifying or diagnosing a problem, adjusting medications, and ensuring treatment needs were identified and addressed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 had adequate interventions and supervision in place to prevent accidents for Resident #1. Resident #1 had seven falls in 1 month (11/19/24, 11/25/24, 11/27/24 x2, 12/11/24 x2, and 12/13/24), the last of which resulted in injuries and hospitalization. An IJ was identified on 12/19/24. The IJ template was provided to the facility on [DATE] at 7:15 pm. While the IJ was removed on 12/21/24, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm because the facility needed to monitor the implementation of the plan of removal. [...]

Inspectors wroteBased on interviews and record review, the facility failed to utilize the services of a registered nurse for at least eight consecutive hours per day, seven days per week for 4 days out of 5 days (11/19/24, 11/25/24, 11/27/24, and 12/11/24) reviewed for nursing services. The facility failed to ensure a registered nurse was scheduled for eight consecutive hours per day, seven days per week on the following dates: 11/19/24, 11/25/24, 11/27/24, and 12/11/24. This deficient practice could place residents at risk of not receiving adequate care.

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 of the resident that meet professional standards of quality of care for 2 of 4 residents (Resident #1 and Resident #4) reviewed for baseline care plan. The facility failed to initiate a baseline care plan within 48 hours of the admission date for Resident #1 and Resident #4. This failure could affect newly admitted residents and place them at risk of not receiving continuity of care and communication among nursing home staff to ensure their immediate care needs were met.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's 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 2 of 4 residents (Resident #1 and Resident #4) reviewed for care plans. The facility failed to develop a person-centered care plan with interventions that addressed: 1. Resident #1's ADL needs; risk for falls; cognitive deficits, dietary needs, therapy; and discharge planning. 2. Resident #4's ADL needs, cognitive deficits, dietary needs, hospice, medication side effects, treatments, and medications. This deficient practice could affect residents and place them at risk for not having their needs and preferences met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to review and revise resident care plans after each assessment for 1 of 4 residents (Resident #1) reviewed for care plan revision/timing. The facility failed to ensure Resident #1's care plan was revised to reflect falls on (4) occasions. This deficient practice could affect residents the care/services and may cause a delay in treatment and/or decline in health.

Inspectors wroteBased on interviews and record review, the facility failed to implement their written policies and procedures to report, prohibit, and prevent abuse for 2 of 2 residents (Resident #1 and #2) and 1 of 3 staff(CNA E) reviewed for developing and implementing abuse and neglect policies 1. The facility failed to develop and implement abuse policies for reporting abuse to the State Reporting Agency. 2. The facility failed to develop and implement abuse policies for review of an employee EMR and criminal history at least once every 12 months. These failures could place residents at risk of abuse, neglect, and misappropriation of property.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, and neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately but not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the State Survey Agency in accordance with State law through established procedures for 2 of 2 residents (Resident #1 and Resident #2) reviewed for reporting. 1. The facility failed to report to the State Survey Agency when Resident #1 had an unwitnessed fall and broke her neck. 2. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 3 residents (Resident #3) reviewed for pharmacy services. The facility failed to administer Resident #3's morning medications which included 7 medications within the facilities policy window for administration of medications. This failure could place residents at risk of not receiving the therapeutic effects of their prescribed medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 8 staff (LVN A) reviewed for staff qualifications. The facility failed to ensure LVN A transferred her nursing license to Texas from Colorado within 60 days of establishing residency in Texas. This failure could place residents at risk of not receiving care and services from staff who were properly licensed.

Inspectors wroteBased on observations, interviews, 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, in that: 1. The overhead light in the kitchen storage room was not working. 2. A bag of 2 dozen hard boiled eggs in the refrigerator was not labeled or dated. 3. A bag of shredded cheese in the refrigerator was not labeled or dated. 4. A bag of 30 ham slices in the refrigerator was not labeled or dated 5. The temperature test strips for the dish machine were wet and could not be used. 6. The ceiling vent across from the dish machine had mold around the edges of the vent. 7. The grill vent above the dish machine hood cover was covered with dirt and grease. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 5 residents (Resident #27) observed for nursing care and 8 of (Resident #36, Resident #41, Resident #56, Resident #58, Resident #66, Resident #80, Resident #91, and Resident #105) of 25 residents reviewed for privacy, in that: 1. The Treatment nurse did not close Resident #27's window curtain while providing wound care for the resident. 2. Shower sheets for Resident #27, Resident #36, Resident #41, Resident #56, Resident #58, Resident #66, Resident #80, Resident #91, and Resident #105 with the residents' names and details about their medical were found on a table on the 200 hallway. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on interview and record review, the facility failed to designate an interdisciplinary team member responsible for collaborating and communicating with hospice representatives. This deficient practice could place residents who receive hospice services at risk of receiving substandard care due to miscommunication between their hospice and facility caregivers.

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 infection for 1 of 5 residents (Resident #28) reviewed for infection control, in that: CNA B and CNA C failed to wash or sanitize their hands or change their gloves after touching the trash can and the privacy curtain before starting incontinent care. This deficient practice could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for residents, staff, and visitors, in that: Two containers of cleaning fluids with hazardous material warning labels were found within the shower room of the facility's 200 hallway. This deficient practice could place residents at risk of coming into contact with hazardous materials.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 26 residents (Resident #13) whose assessments were reviewed, in that: Resident #13's Quarterly MDS assessment incorrectly documented the resident as not receiving an antidepressant. This failure could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that 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 1 of 5 (Resident #73) residents reviewed for comprehensive assessments. The facility failed to ensure that Resident #73's care plan documented interventions for the resident's weight loss of 13 pounds. This deficient practice could place residents at risk of not receiving proper care and services .

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #102) of 7 residents reviewed for unnecessary medications, in that: Resident #102 was prescribed a psychotropic drug for anxiety without a documented diagnosis of anxiety in the clinical record. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate was not 5% or greater. The facility had a medication error rate of 8%, based on 2 errors out of 25 opportunities, which involved (Resident # 15) and 1 of 2 staff (CMA D) reviewed for medication errors. The facility failed to ensure CMA D administered medications according to the physician's orders and per professional standards, which resulted in an 8% medication administration error rate. This deficient practice could place residents at risk of not receiving the therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 (refrigerators in resident room [ROOM NUMBER] and room [ROOM NUMBER]) of 5 residents' personal refrigerators reviewed, in that: The personal refrigerators in two residents' rooms contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled.

Inspectors wroteBased on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition for 1 (Resident #1) of 5 residents reviewed for a change of condition. The facility failed to notify the physician and follow up on a change in condition for Resident #1 after he complained of nausea, abdominal pain, and decreased oral intake on 12/31/23. Resident #1 expired at the hospital on 1/1/24. An IJ was identified on 1/6/24. The IJ template was provided to the Administrator on 1/6/24 at 7:35 pm. While the IJ was removed on 1/10/24, the facility remained out of compliance at a scope of isolated and a severity level of actual harm due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to monitor Resident #1 following an episode during which he became unresponsive with low blood pressure on [DATE] and failed to notify the physician related to Resident #1 after he complained of nausea, abdominal pain, and decreased oral intake on [DATE]. Resident #1 expired at the hospital on [DATE]. An IJ was identified on [DATE]. The IJ template was provided to the Administrator on [DATE] at 7:35 pm. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive care plan was developed within 7 days after the completion of the comprehensive assessment and failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment there was an update for 3 of 21 residents (Residents #5, #38 and #86) whose care plan was reviewed, in that: 1. The facility failed to update Resident #5's care plan when her order for Carbidopa/Levodopa was discontinued. 2. The facility failed to update Resident #38's care plan when she discontinued hospice services. 3. The facility failed to develop a comprehensive care plan for Resident #86 within seven days after completion of the comprehensive assessment. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the services of a Registered Nurse for at least eight consecutive hours a day, 7 days a week. The facility failed to ensure a Registered Nurse was present at the facility on: 01/08/2023, 01/21/2023, 01/22/2023, 02/11/2023, and 02/12/2023. This deficient practice could place residents at risk of receiving inadequate nursing care.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 4 residents (Residents #46, and #201) reviewed for pharmacy services. 1. The facility failed to ensure Resident #46 was administered medications according to physician parameters. 2. The facility failed to ensure Resident #201 was administered medications according to physician parameters. These deficient practices could place residents at risk of not receiving the intended therapeutic benefit of the medications, could result in a worsening or exacerbation of chronic medical conditions, hospitalization and or a diminished quality of life.

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 in 2 of 10 medication storage carts (Med Aide Cart and Nurses Treatment Cart) reviewed for medication storage. 1. The facility failed to ensure the Med Aide Cart was locked in the 100-hallway when it was left unattended. 2. The facility failed to ensure the Nurses Treatment Cart locked in the common, seating area near the 100-hallway Nurses station when it was left unattended. These deficient practices could place residents at risk of medication misuse and diversion.

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 kitchen sanitation. 1. The facility failed to ensure foods were properly sealed, labeled, dated and stored. 2. The facility failed to ensure equipment (the commercial toaster) was not soiled and the facility failed to ensure the walls were not soiled with any gummy substances. 3. The facility failed to ensure the commercial fryer did not contain murky oil and was clean. These deficient practices could place residents at-risk by contributing to foodborne illness, poor intake, and/or weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 23 residents (Resident #97) reviewed for quality of care, in that: Resident #97 hit her head during a fall and the facility failed to ensure four scheduled neurological assessments were completed following the fall. Resident #97 experienced two changes in condition within three days of her fall and her physician was not notified of the missing neurological assessments or of the changes in condition. The physician did not have the opportunity to assess the resident or to provide treatment, and no interventions were implemented on the resident's behalf. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to dispose of garbage and refuse properly for 1 of 1 garbage dumpster reviewed for disposal of garbage and refuse. The facility failed to properly dispose of garbage. This deficient practice could place residents at risk of attraction of vermin and rodents, and possible disclosure of residents' sensitive personal information.