Rowlett Health and Rehabilitation Center

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 10 of 15 resident rooms on the 500 hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), and residents eating in the dining room, reviewed for environment. Based 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 10 of 15 resident rooms on the 500 hall (Resident rooms #1, #2, #3, #4, #5, #6, #7, #8, #9 and #10), and residents eating in the dining room, reviewed for environment. 1. [...]

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 the facility's only kitchen, reviewed for food and nutrition services. Based 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 the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 2. The facility failed to ensure food in the freezer and dry storage area was labeled and dated when stored. 3. The facility failed to ensure expired food in the refrigerator and dry storage area was discarded. 4. [...]

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 two (Resident #76 and Resident #79) of twenty-four residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #76's room was in a position that was accessible to the resident on 07/22/2025. The facility failed to ensure the call light system in Resident #79's room was in a position that was accessible to the resident on 07/22/2025. 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 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 two (Resident #1 and Resident #63) of six residents reviewed for respiratory care. The facility failed to ensure Resident #1's yankauer suction tip (device used to suction fluids and secretions from the oral cavity) was stored in a bag when not in use on 07/22/2025. The facility failed to ensure Resident 63's oxygen tubing was properly stored in a bag when not in use on 07/22/2025. This failure could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased 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 (Resident #78) of six residents observed for infection control. The facility failed to ensure that CNA E changed gloves and performed hand hygiene, did not carry gloves in her pocket, and did not blow on her hands to dry the hand sanitizer, while providing incontinent care to Resident #78 on 07/22/2025. These failures could place the residents at risk of cross-contamination and development of infections.

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 food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food in the facility's refrigerator, was labeled and dated according to guidelines. The facility failed to ensure food in the facility's freezer, was labeled and dated according to guidelines. The facility failed to ensure the ice machine scoop holder, located in the facility's kitchen, was cleaned. The facility failed to ensure kitchen equipment (storage bins) was cleaned and sanitary. These failures could place residents at risk for cross contamination and other air-borne illnesses.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for areas in the facility for 6 (Resident room [ROOM NUMBER], #513, #515, #517, #519, and #522) of 14 resident rooms observed for a safe, clean, comfortable, and homelike environment. The facility failed to ensure that Residents room [ROOM NUMBER], #513, #515, #517, #519, and #522 were cleaned and sanitized. This deficient practice 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 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 #78) of eight residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #78's rooms were in a position that was accessible to the residents. 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 observations, interviews and record reviews, the facility failed to ensure that a resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents ' choices for 1 (Resident #46) of 1 resident reviewed. for quality of care. The facility failed to to obtain physician orders and assess Resident #46 for a scoop mattress and obtain physician orders prior to installing the scoop mattress. This failure could prevent the resident to be free from of any physical or chemical restraints.

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 2 (Resident #321 and Resident #322) of ten residents reviewed for respiratory care. The facility failed to ensure Resident #321's nebulizer masks and nasal cannula was properly stored. The facility failed to ensure Resident #322's nasal cannula was properly stored. The facility failed to ensure a Physician's Order was in place for Resident #322's oxygen administration. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased 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 two (Resident #49 and Resident #89) of eight residents observed for infection control. The facility failed to ensure that CNA D changed his gloves and perform hand hygiene while providing incontinent care to Resident #49 and Resident #89. This failure could place the residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assure that medications were secure and inaccessible to unauthorized staff and residents for 1 (medication aide cart) of 4 medication carts reviewed for medication storage. The facility failed to ensure the medications were placed inside of the medication cart when MA H left the medication cart on the hallway. This failure could place residents at risk of ingesting unprescribed medications resulting in adverse health consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure special eating equipment and utensils were provided for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals and snacks for 1 of 3 residents (Resident #69) reviewed for feeding assistance. The facility failed to provide Resident #69 an adaptive aid to assist her to eat independently. The failure could place residents who required adaptive feeding equipment at risk for loss of self-worth and empowerment for independent eating, which could lead to unplanned weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records on each resident that are complete, accurately documented and readily accessible for one (Resident #85) of five residents reviewed for clinical records. The facility failed to ensure that Resident #85's physician's orders for tramadol were written to be given orally and not enterally. This failure could place residents at risk of inaccurate medical records that could affect monitoring and medical services provided.