San Antonio North Nursing and Rehabilitation

Inspectors wroteBased on 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 (Resident #1) of 8 residents reviewed for medications. Facility nurses did not update Resident #1's physician order regarding Acetaminophen Capsule 500 mg - Give 2 capsules by mouth three times a day for chronic pain - Give with Tramadol when the resident's primary care physician changed the resident's Tramadol from schedule medication to PRN (as needed for pain) medication on 06/04/2026. This failure could place the residents at risk of not receiving therapeutic doses of their medication.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #1 and #2) out of 8 residents reviewed for medical records in that: 1. Facility wound care nurse did not document in Resident #1's treatment administration record and nursing progress note on 06/02/2026 scheduled wound care date. 2. Facility staff did not document details of a facility reported incident that reportedly occurred on 6/8/2026 at 10:10am in Resident #2's electronic health record. Theses failures could place residents at risk for missed treatment and medications which could result in decline in healing and well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be informed of and participate in his or her treatment including the right to be fully informed in language that he or she understood of his or her health status, including his or her medical condition for 1 of 1 resident (resident #3) reviewed for resident rights. The facility failed to have an effective method of communication with Resident #3 who was deaf and mute This failure could place residents at risk of poor communication and a demoralized sense of self-esteem and psychosocial wellbeing.

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 disease and infection for 1 of 1 resident (Resident #3) reviewed for infection control, in that: The facility failed to ensure ADON A wore a gown while providing wound care for Resident #3 who was on enhanced barrier precaution. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involved abuse, to the State Survey Agency for 1 of 4 residents (Resident #1) reviewed for abuse. The facility did not report to the State Survey Agency (HHSC) an allegation of Resident #1 being sexually abused by three unknown men in the facility on 4/1/16. This failure could place residents at risk for harm to include sexual abuse, a diminished quality of life, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to voice grievances to the facility or other agency or entity that hears grievances without discrimination or reprisal and without fear of discrimination or reprisal. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 7 residents (Resident #2) reviewed for resolution of grievances. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration dates for 2 of the facility's 5 medication carts (1 cart for the 200-hall and 1 cart for the 400-hall) reviewed for medication storage. The Medication Aide 200-hall medication cart had 4 pill form medications stored in a small plastic cup and not in pharmacy labeled containers. The Nurse 400-hall medication cart had 3 pill form medications stored in a small plastic cup and not in pharmacy labeled containers. These failures could place residents at risk of not receiving the therapeutic effects of their medication.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident had the right to be informed of and participate in his or her treatment including the right to be fully informed in language that he or she understood of his or her health status, including his or her medical condition for 1 of 1 resident (Resident #1) reviewed for resident rights. 1. The facility failed to have an effective method of communicating with Resident #1 who was deaf and mute. This failure could place residents at risk of poor communication and a demoralized sense of self-esteem and psychosocial wellbeing.

Inspectors wroteBased on interview, and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result 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 1 of 6 residents (Resident #3) reviewed for reporting alleged violations. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to evidence that all alleged violations were thoroughly investigated and prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress, and reported the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation was verified appropriate corrective actions were taken for 1 of 6 residents (Resident #3) reviewed for abuse. On 2/22/2026 the facility failed to investigate and report the results of the investigation to the State Agency an allegation of sexual abuse when a hospice RN alleged Resident #3 was sexually abused. [...]

Inspectors wroteBased on observations, interviews, and record reviews 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 are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, for 1 of 6 resident (Resident #1) reviewed for care plans. The facility failed to ensure the care plan included instructions necessary for implementing communication interventions with Resident #1 who was deaf and mute. This failure could place residents at risk of harm due to poor communication.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety, for 1 of 5 residents medication carts (200-hall medication cart) reviewed for food safety. The facility stored resident's pudding and jelly in the Resident's medication cart without labels and dates to indicate if the foods were safe to serve. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, sanitary, comfortable, and homelike environment for 1 of 6 residents (Resident #1). The facility failed to ensure Resident #1's room was clean, sanitary and did not have a strong smell of urine. This failure could place residents at risk of living in unsafe, unsanitary, and uncomfortable conditions which could lead to a decline of mental and physical health and decreased social interactions.

Inspectors wroteBased on observations and interviews, the facility failed to provide a safe and homelike for 3 of 3 residents' rooms observed for electricity and 3 of 3 residents affected (Resident #1, Resident #2, and Resident #3). Rooms #10 (Resident #3), #11 (Resident #1), and #12 (Resident #2) had no over the bed lights and electrical issues with other electronics. This failure could place residents at risk a lack of comfort, risk for falls, and a diminished quality of life in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the rights of the residents to be from from abuse for 3 of 3 residents reviewed for abuse. Resident # 6 was abused by LVN B.Resident #7 was abused by LVN B.Resident #8 was abused by LVN B.These failures could place residents at risk of more abuse and diminish their quality of life. Record review of Resident #8's face sheet dated 1.6.2026 revealed an [AGE] year-old female was admitted on 3.1.2019 with diagnoses: anxiety disorder, hypertensive heart disease without failure (high blood pressure that causes structural changes to the heart), and major depressive disorder. Record review of Resident #8's Care Plan dated 12.10.2025 revealed she was care planned for major depressive disorder, anxiety, and fall precautions due to dizziness and giddiness. [...]

Inspectors wroteBased on interview and record review, the facility failed to utilize nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1of 1 facilities. The facility failed to ensure Staff Member A had an MA certificate from [DATE] to [DATE] for a total of 88 shifts and passed medications to residents. This failure could place residents at risk of medication errors, inaccurate assessment, and illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the attending physician must document in the resident's medical record that the identified irregularity has been reviewed and what, if any, action has been taken to address it for 1 of 7 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to document review and response to irregularities identified in Resident #1's medication regimen in August and September 2025. This failure could result in unintended effects of medications and/or 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 two of seven residents (Resident # 41 and Resident #2) reviewed for privacy. 1. The facility failed to ensure MA B locked the computer, after he walked away and left the computer unattended, which exposed Resident #41's morning medication list. 2. The facility failed to ensure the privacy curtains in Resident #2's room were able to completely close around his bed to provide Resident #2 privacy during wound care. These failures could place residents at risk of having medical information exposed to others and of loss of personal privacy, causing residents to feel uncomfortable and disrespected.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents had a right to a safe, clean, comfortable, and homelike environment for 2 (Residents #52 and #87) of 30 residents reviewed, in that: 1. The bathroom door facing the interior of the bathroom used by Resident #52 had scrape marks and the lower section of the door was unpainted. 2. The entrance to the bathroom used by Resident #87 had a 3inch rust area on the left door post and the toilet was not secured to the floor base. These failures could result in residents not having a safe, clean, homelike environment which could result in low self esteem and a diminished quality of life.

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 facility in that: 1. The facility failed to replace dirty overhead ceiling tiles in the main kitchen area. 2. The facility failed to replace a light bulb fixture in the main kitchen area. 3. The facility failed to clean an overhead ceiling vent in the dish room. 4. The facility failed to repair a wall penetration and broken floor molding in the employee bathroom in the main kitchen area. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records that were complete and accurately documented for 1 (Resident #11) of 25 residents reviewed for clinical records, in that: Resident #11's Medication Administration Record, dated July 2025, had blank spaces on July 5, 2025 rather than documentation. This deficient practice could cause miscommunication among the resident's caregivers and result in improper care.

Inspectors wroteBased on observation, interview and record review, the facility failed in 1 of 2 garbage dumpsters to dispose of garbage and refuse properly. The facility failed to ensure the sliding doors on both sides of the dumpster were completely closed. This deficient practice could place residents at risk for exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 Maintenance and Housekeeping Office reviewed, in that: The Maintenance and Housekeeping Office, in which were stored tools and cleaning equipment, was observed with the door ajar and no staff in attendance. This deficient practice could result in residents, staff, or the public coming into contact with tools and cleaning equipment that were unsafe.

Inspectors wroteBased on interview, and record review, the facility failed to ensure resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #2) reviewed for incontinent care. The facility failed to ensure Resident #2 was not left sitting in urine in a chair in the dining room on the evening of 05/18/2025. This failure could place residents at risk of skin breakdown and infection.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, maintaining medical records on each resident that are complete and accurately documented for 1 of 2 residents (Residents #1) reviewed for clinical records. The facility failed to ensure Resident #1's completion or refusal of prescribed wound care was accurately documented on her Treatment Administration Record (TAR) for 4 (4/11/2025, 4/18/2025, 4/29/2025 and 5/2/2025) of 14 treatment days between 04/01/2025 through 05/20/2025. This failure could place residents at risk of not receiving the care and services needed due to inaccurate or incomplete clinical records.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 medication carts (Med Cart 1) reviewed for medication storage. The facility failed to ensure Med Cart 1 was locked while unattended on 5/11/25. This failure could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to assist residents in obtaining routine and 24- hour emergency dental care to meet the needs of 1 of 3 residents (Resident #1) reviewed for dental services in that: The facility did not assist Resident #1 with obtaining dental services when her top dentures were reported missing on 9/29/24 . This failure could place residents at risk of not having their oral health care needs met.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 3 of 37 residents (Residents #3, #6, and #8) reviewed for reasonable accommodations, in that: 1. Resident #3 had no access to her call light that was observed on the floor approximately four feet away from Resident #3. 2. Resident # 6 had no access to his call light that was observed on the floor behind the headboard of Resident #6's bed. 3. Resident #8 had no access to his call light that was observed on the floor approximately five feet away from Resident #8. This deficient practice could place residents not being able to use call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents had the right to personal privacy during personal care for 1 of 3 residents (Resident #3) reviewed for privacy, in that: CNA E and CNA J did not maintain privacy while providing incontinent care for Resident #3. This failure could place residents who require assistance with incontinent care at risk of being exposed.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 11 residents (Resident #1) reviewed for accuracy of records, in that: The facility failed to ensure the treatment administration records (TAR) for Resident #1 accurately reflected the administration of the bilateral wound treatment on 01/03/2025 and 01/07/2025. This deficient practice could place residents receiving treatments at risk for not receiving appropriate care.

Inspectors wroteBased on record review, interview, and observation, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly discharge from the facility for 1 of 3 residents (Resident #1) reviewed for discharge rights, in that: The facility failed to ensure Resident #1's legal guardian was sufficiently prepared and oriented for Resident #1's transfer to hospital. This failure could place residents at risk of being discharged without preparation, causing a disruption in their care and services and denying them a voice regarding their treatment plan.

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, for 2 of 3 the residents (Residents #4 and #56) reviewed for oxygen in that: The facility faield to ensure Residents #4 and #56 did not have an empty oxygen humidifier bottle on the oxygen concentrator dated 5/12/24 while in use. This deficient practice could place residents who received oxygen therapy at risk for an increase in respiratory complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. The facility failed to repair a broken electrical outlet in a Resident's room, fix a roof leak in a resident's room, repair a section of broken floor paneling in a resident hallway corridor, replace a damaged section of ceiling tile in a resident hallway corridor. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteBased on Observations, Interview and record review , the facility failed to 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 2 of 2 residents (Residents #46 and #55) reviewed for call light. The facility failed to ensure Residents #46's and #55's call lights were within reach. This failure could place residents at risk of achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to reside in a safe, clean, comfortable, and homelike environment for 2 residents (Residents #14 and #33), in that: 1. Barrels of soiled linens and trash were stored in the shower area of Resident #14's restroom. 2. Resident #33's shower chair and the floor of the shower area in her restroom were soiled with a dark brown substance which appeared to be mud or feces. These deficient practices could lead to diminished quality of life and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1of 6 residents (Resident #55) reviewed for accidents and hazards. The facility failed to ensure Resident #55 did not have access to an electronic cigarette. This failure could place residents at risk of injury or harm, as well as contribute to avoidable accidents.

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 of 3 residents (Resident #20) reviewed for unnecessary medications, in that: The facility failed to ensure Resident #20 was prescribed a psychotropic drug for anxiety no longer than 14 days PRN . 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 maintain and ensure safe and sanitary storage of residents' food items for 1 (refrigerator in resident room [ROOM NUMBER]B) of 3 residents' reviewed in that: The facilty failed to ensure the personal refrigerators in one residents' rooms contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming spoiled foods.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the garbage storage area in a manner to prevent the harborage of pests for 1 of 1 facility. The facility failed to close a garbage bin lid on a separate garbage disposal unit on two separate occasions. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 6 residents (Resident #1) reviewed for foot care. The facility failed to ensure Resident #1 was provided with adequate foot care and access to podiatry services. This failure could place residents at risk of discomfort, poor foot hygiene, or a decline in residents' physical condition.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 (Resident #1) of 13 residents reviewed for comprehensive care plan, in that: LVN A failed to follow the plan of care on 05/01/2024 which required Resident #1 to be monitored and a PCP to be notified if Resident demonstrated a fear of being alone. Resident #1 attempted suicide on 05/02/2024. This failure resulted in the identification of Immediate Jeopardy (IJ) on 05/26/2024 at 06:00 p.m. While the IJ was removed on 05/28/2024, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility's need to monitor the implementation of the plan of removal. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure a resident who displayed or was diagnosed with a mental disorder or psychosocial adjustment difficulty received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being for 1 (Resident #1) of 13 residents reviewed for psychosocial concerns. LVN A failed to put interventions in place or promptly arrange for psychiatric services for Resident #1 after he displayed increased signs of fear on 05/01/2024. Resident #1 attempted suicide on 05/02/2024. This failure resulted in the identification of Immediate Jeopardy (IJ) on 05/26/2024 at 06:00 p.m. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to monitor based on the comprehensive assessment of a resident, residents who use psychotropic drugs for the efficacy and adverse consequences of prescribed psychotropic medications for 6 (Resident #1, Resident #2, Resident #3, Resident #4, Resident #5, and Resident #6) of 12 residents reviewed for medication management. - The facility failed to monitor Resident #1 for side effects and observe for the behaviors of the antidepressant medication Sertraline HCl and the antianxiety medication Hydroxyzine HCl. - The facility failed to monitor Resident #2 for side effects and observe for the behaviors of the antianxiety medication Ativan, the antidepressant medication Citalopram, and the anticonvulsant medication Trileptal. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 (Resident #1) of 13 residents reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #1 attempted suicide. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse and neglect for 1 (Resident #1) of 13 residents reviewed. The facility did not have evidence that a thorough investigation was completed for Resident #1 who had attempted suicide. This failure could place residents at risk of incidents not being thoroughly investigated.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 44% based on 11 errors out of 25 opportunities, which involved 1 (Resident #7) of 4 residents reviewed for medication errors. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #2, #3, #1) reviewed for infection control, in that: 1. During wound care of Resident #3, LVN D made several passes in multiple directions with the same gauze to clean the wound; she made several passes in multiple directions to dry the wound, and when applying the ointment to the wound, she made several passes with the tongue depressor with ointment on it without discarding the used tongue depressor and using a new one with each new pass. 2. During incontinent care for Resident #2, CNA C washed her hands before starting care and dried her hands with one soaked paper towel for both hands; [...]

Inspectors wroteBased on observation, 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 one resident (#1) of four residents reviewed for infection control. CNA A did not change her gloves or sanitize her hands when she finished cleaning Resident #1's feces from his anus and placed a clean brief onto him This deficient practice could place residents at risk of developing a urinary tract infection.

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 in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored food was properly labeled and dated. 2. The facility failed to ensure frozen foods were properly labeled and dated. 3. The facility failed to ensure expired foods were not in the pantry, refrigerator, and freezer. These failures could place residents at risk for food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all mechanical, electrical and patient care equipment in safe operating condition for one of two ovens (oven #1 and oven #2) reviewed in the facility's only kitchen for essential equipment 1. The facility failed to ensure oven #2 was maintained, and the griddle grease can was properly cleaned in accordance with manufacturer's instructions. 2. The facility failed to ensure that one of the two ovens in the kitchen could be safely operated after the griddle grease can was welded to the oven and can't be removed. These failures could place residents at risk of not having their food send out timely.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident was provided the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for three of eight residents (Residents #8, #54 and #48) reviewed for quality of life. 1. The facility failed to ensure the environment in and around Residents #8 and #54's room was free of unpleasant odors. 2. The facility failed to ensure Resident #48 was able to spend time outside per his preferences and care plan. These failures could place residents at risk of a diminished quality of life, indignity, and depression.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 of 5 residents (Residents #6, 8, 9, 14, and 27) reviewed for ADLS. The facility failed to ensure Residents #6, #8, #9, #14, and #27's fingernails were trimmed, smooth, and clean. This failure could place residents at risk of scratches, infection, and indignity.

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 #58) reviewed for personal privacy and confidentiality of records. The facility failed to protect the personal healthcare information of Resident #58 which was visible on a computer screen in the hallway while MA D went into his room to administer medications. This failure could place residents at risk for loss of privacy and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 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 2 of 2 residents (Resident #10 and Resident #8) reviewed for incontinence care. 1. The facility failed to ensure Resident #10's urinary catheter bag was emptied and not backing up into the catheter tubing. 2. The facility failed to ensure Resident #8 received timely incontinent care, which led to a strong foul odor about her person. This failure could place residents at risk of urinary tract infections.

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 one of two medication carts (2nd floor cart) reviewed for medication storage. The facility failed to ensure the Medication Aide cart for the 2nd floor was locked and supervised. This failure could place residents at risk of ingesting unprescribed and/or expired medications resulting in adverse health consequences.

Inspectors wroteBased on observation and interview and record review the facility failed to ensure resident rooms measured at least 80 square feet per resident in multiple resident bedrooms and at least 100 square feet in single resident rooms for 8 of 59 resident rooms (Rooms 8, 9, 10, 33, 40, 41, 42 and 43) reviewed for square footage. The facility failed to ensure resident rooms 8, 9, 10, 33, 40, 41, 42, and 43 were the required 80 square feet per resident. This failure could place residents at-risk for problems in residents' activities of daily living and could compromise resident's privacy.