San Antonio Wellness & Rehabilitation

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 nutrition services. The facility failed to ensure the commercial bar soda/juice gun dispenser was free from dirt and debris buildup. The facility failed to ensure that the DNS, Cook, and Dietary Aide were wearing hair restraints during food preparation during the initial brief tour of the kitchen. The facility failed to ensure that the DNS, Cook, and Dietary Aide were wearing hair restraints appropriately during follow-up visits to the kitchen. The facility failed to ensure the DNS was practicing hand hygiene when exiting and reentering the kitchen during follow-up visits to the kitchen. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and stored in locked compartments for 2 of 3 residents (Residents #36 and #21) and 1 of 11 medication carts reviewed for storage. 1. Resident #36's insulin Glargine (Lantus) Solos Flex Pen for diabetes had no open date, found inside 500 and 600-hall nursing cart on 02/18/2026. 2. Resident #21's insulin Novolog 70/30 Flex Pen for diabetes had no open date, found inside 200-hall nursing cart on 02/18/2026. 3. The facility failed to ensure 1 of 11 medication carts was kept locked or under direct observation of authorized staff in an area where residents could access it on 2/19/2026. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #4) reviewed for incontinence care. When LVN-A was providing incontinent care to Resident #4 on 02/19/2026, LVN-A did not clean the resident's left side area of buttock. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards for 1 (Resident #6) of 1 resident reviewed for intravenous fluids. LVN-B flushed the medication port of Resident #6's central line (inserted central catheter: used to deliver medications and other treatments directly to the large central veins near the heart) with 10 ml normal saline when administering antibiotic dose. However, the physician order said, Flush IV (intravenous) line with 5 ml normal saline before and after medication administration. This failure could affect residents by placing them at risk for receiving diluted medication.

Inspectors wroteBased on observation, interviews, 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 for 1 (Residents #77) of 4 residents reviewed for respiratory care. Resident #77's CPAP (continuous positive airway pressure) mask was not covered in a plastic bag when it was not used on 02/17/2026. This failure could affect residents with oxygen therapy and could lead them to lack of care including possible infection by not following infection control.

Inspectors wroteBased on observations, interviews, 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 (400-500-600-hall medication aide cart) out of 6 medication carts and 1 (Resident #73) out of 3 residents reviewed for pharmacy services. 1. There was one bottle of Nutricia Pro-Stat expired 01/02/2026 found inside 400-500-600-hall medication aide cart on 02/18/2026. 2. Facility nurses opened Resident #73's insulin pen (Glargine-Lantus) on 01/07/2026 and used the insulin on 02/18/2026. However, the label of the insulin indicated Discard 28 days after opening, and 28th day was 02/04/2026. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 (Resident #106 and #132) of 24 residents reviewed for infection control practices. 1. Medication Aide-C measured Resident #106's blood pressure without cleaning the blood pressure cuff on 02/19/2026. 2. When CNA-F was providing peri care to Resident #132 on 02/19/2026, CNA-F changed her gloves without washing or sanitizing her hands. This deficient practice could place residents at risk for cross contamination and infections.

Inspectors wroteBased on interviews 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 4 residents (Resident #1) reviewed for accuracy of medical records. LVN N failed to document Resident #1's wound care treatment on Resident #1's medication administration record for December 26, 2025. This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility was changed for one of one resident (Resident #1) reviewed for room change. The facility did not provide Resident #1 with a written notice prior to a room change or the right to refuse on 06/16/2025. This deficient practice could place residents at risk for being displaced without notice and/or reason to accommodate other individuals.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free from involuntary seclusion and any physical restraint not required to treat the resident's medical symptoms for one of six (Resident #1) residents reviewed for involuntary seclusion. The facility failed to ensure Resident #1 met criteria to remain on the secure unit per secure unit criteria. This failure could place residents who resided on the secure unit at risk for feelings of isolation and anxiety.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were complete and accurately documented for two of six residents (Resident #1 and Resident #2) reviewed for medical records accuracy. 1. The facility failed to ensure Resident #1's orders for facility admission and for secure unit admission were reflected in the active orders. 2. The facility failed to ensure Resident #2's orders for facility admission and for secure unit admission were reflected in the active orders. These deficient practices could affect residents whose records are maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, 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 where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 6 residents (Residents #12, and #18) reviewed for freedom from abuse and misappropriation.1. The facility failed to report the incident of misappropriation on 5.2.25 for Resident # 12 missing a gold diamond necklace. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 1 of 8 residents (Resident #18) reviewed for abuse and neglect. The facility did not investigate an incident in which Resident #18 made a grievance that a staff member was rough with her and did not stop perineal care when requested. 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 interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 6 residents (Resident #15) reviewed for care plan revisions. The facility failed to ensure Resident #15's care plan was comprehensive and updated to reflect Resident #15 had an incident of resident-to-resident aggression. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 3 patios reviewed for entrapment and lack of supervision. 1. The secured enclosed patio by the 100-300 hall dining room was accessed by a door that would allow residents, staff, and the public to exit to the secured enclosed patio but would lock behind anyone and would prevent access back into the dining room. 2. The secured enclosed patio by the 400-600 hall dining room was accessed by a door that would allow residents, staff, and the public to exit to the secured enclosed patio but would lock behind anyone and would prevent access back into the dining room. This failure could place residents, staff, and the public at risk for entrapment.

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 observed. The facility failed to ensure dietary staff used proper hand hygiene during meal preparation. This failure could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

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, recognizing each resident's individuality for 1 of 6 Residents (Resident #48) reviewed for dignity. CNA F walked into Resident #48's room without knocking and while Surveyor and Resident #48 were having a discussion about his medical concerns. This deficient practice could affect any resident and contribute to residents feeling like their feelings, privacy or dignity does not matter.

Inspectors wroteBased on observation, interviews, and record reviews 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 8 residents (Resident #4) reviewed for grievances. The facility failed to create a greience for Resident #4 who made a grievance to LVN D, LVN C, CNA A, and The BOM alleging she did not receive medications on Sunday 10/27/2024. This failure could place residents at risk for not having their grievances heard and or resolved.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 1 of 8 residents (Resident #16) reviewed for mechanical soft diet needs. 1. The facility failed to follow the physicians' orders and the Speech Language Pathologist's (SLP) recommendations for Resident #16's mechanical soft diet and served Resident #16 potato chips on 11/05/2024 for lunch. 2. The facility failed to follow the physicians' orders and the Speech Language Pathologist's (SLP) recommendations for Resident #16's mechanical soft diet and served Resident #16 potato chips on 11/05/2024 for dinner. This failure could place residents at risk for harm by aspiration of food into the lungs due to swallowing difficulties.

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 #1) reviewed for infection control, in that: The facility failed to ensure LVN A changed her gloves when moving from a dirty to clean task and failed to use appropriate hand hygiene between glove changes when she provided incontinent care to Resident #1. 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 ensure they assisted residents in obtaining routine dental care for 1 of 5 Resident (Resident #2) whose records were review for dental services. Nursing staff failed to refer Resident #2 for dental services since her admission; for 6 months. This deficient practice could affect residents in need of dental services and result in the development of infections and a decline in physical condition

Inspectors wroteBased on interview and record review the facility failed to ensure in response to allegations of abuse, were reported immediately, but not later than 2 hours after the allegation was made, when the events that caused the allegation involved abuse for 1 of 5 Residents (Resident #1) whose records were reviewed for abuse. CNA A reported to nursing staff that CNA B slapped Resident #1 on the right upper thigh. Nursing staff failed to follow the chain of command and report it to the ADM right away which delayed the ADM in reporting the allegation of abuse to the State Survey Agency within 2 hours. This deficient practice could affect any resident and contribute to further resident abuse.

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 oral hygiene for 1 of 5 Residents (Resident #2) whose records were reviewed for adl care. Nursing staff failed to clean Resident #2's lips and brush her teeth after breakfast. This deficient practice could affect dependent residents and contribute to poor oral hygiene, tooth decay, infections and decline in physical condition

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a 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 2 of 4 resident (Residents #3 and #20) reviewed for incontinent care, in that: 1. While providing incontinent care for Resident #3, CNA H did not pull back Resident #3's foreskin. 2. While providing incontinent care for Resident #20, CNA G used a back to front motion to clean Resident #'s buttocks. CNA G did not clean Resident #20's anal area. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skillss and techniques to provide nursing and related services for 2 of 4 residents (Residents #3 and #20) by 2 of 4 certified staff (CNA G and CNA H) reviewed for competent staff, in that: 1. While providing incontinent care for Resident #3, CNA H did not pull back Resident #3's foreskin. 2. While providing incontinent care for Resident #20, CNA G used a back to front motion to clean Resident #'s buttocks. CNA G did not clean Resident #20's anal area. These failures could place residents at risk for not receiving nursing services by adequately trained and certified aides and could result in a decline in health and infection.

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 4 residents (Resident #3) reviewed for infection control, in that: While providing incontinent care for Resident #3, CNA H touched the fall matt on the floor with her bare hands and did not wash her hands before putting her gloves on and starting providing care. CNA H did not change gloves and sanitize or wash her hands before touching Resident #3's clean brief. 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 residents are free of any significant medication errors for 1 of 12 residents (Resident #1) reviewed for significant medication errors, in that: The facility did not administer Resident #1's recommended doses for dexlansoprazole [a medication used to reduce stomach acidity and prevent stomach ulcers] and sucralfate [a medication used to coat the lining of the stomach and intestinal ulcers by forming a barrier over the ulcers and protecting the ulcer from further injury] from 11/11/2023 to 11/27/2023, resulting in the resident being sent out to the hospital on [DATE]. These failures resulted in the identification of an Immediate Jeopardy (IJ) on 12/1/23 at 5:37 p.m. [...]

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 4 of 12 residents (Resident #4, #5, #10, and #11) reviewed for pharmacy services in that: 1. The facility did not ensure LVN C did not administer Resident #4's medicated eye drops Brimonidine Tartrate-Timolol [a medication used to treat high fluid pressure in the eye] and Dorzolamide HCl-Timolol [a medication used to treat high fluid pressure in the eye] 5 minutes apart, as per physician's orders. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 12 residents (Resident #5) reviewed for storage of drugs, in that: While preparing Resident #5's morning medications, LVN C left 1 of Resident #5's furosemide pill unattended and unsecured on top of her medication cart. This deficient practice could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 1 (Resident #1) of 3 residents reviewed for accurate medical records in that: LVN A initialed off on Resident #1's MAR indicating she had provided the medication when she had not provided the medication. This deficient practice could result in misinformation about professional care provided.

Inspectors wroteBased on observations and interviews, the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable and for 3 (200 Hall, 300 Hall and 600 Hall) of 6 medication carts in that: 1. The facility failed to ensure expired medications were not found on the 200 Hall and 300 Hall medication carts. 2. The facility failed to ensure the nurse and medication aide medication carts for 600 Hall were not left unattended and unlocked. These deficient practices affect residents who receive medications and could result in less potent or adverse effects and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed for 1 of 1 meal observed in that: 1. The facility failed to ensure all residents received [NAME] Peas with Sauteed Onions with their lunch meal on 10/03/2023. 2. The facility failed to ensure [NAME] Peas with Sauteed Onions was prepared by the recipe. These failures could place residents at risk for dissatisfaction, poor intake, and 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 kitchen reviewed for food nutrition services, in that: 1. The facility failed to ensure [NAME] Y's hairnet was covering his mustache while preparing for lunch. 2. The facility failed to ensure that staff didn't wear facial jewelry while preparing foods. 3. The facility failed to maintain the cleanliness of the ice machine found within the kitchen. These failures could place residents at risk for food contamination and foodborne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to provide effective communications mandatory training for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure effective communication training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required education on the rights of the resident and the responsibilities of a facility to properly care for its resident for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure that quality assurance and performance improvement training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could place residents at risk for injury or improper care due to a lack of training.

Inspectors wroteBased on interview and record review, the facility failed to provide the required compliance and ethics training for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training requirements, in that: The facility failed to ensure compliance and ethics training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective behavioral health training for 8 of 24 employees (MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X) reviewed for training, in that: The facility failed to ensure effective behavioral health training was provided to MA L, CNA M, CNA N, CNA Q, CNA R, CNA B, ADON W and ADON X. This failure could place residents at risk of not attaining or maintaining their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to promote resident self-determination through support of family choice for 1 of 8 residents (Resident #56) reviewed for resident rights. The facility did not follow Resident #56's and the family's request to not have resident be tube fed. This failure could place residents at risk for feelings of depression, lack self-determination and decreased quality of life.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to accurately reflect the resident's status on the quarterly MDS for one (Resident #25) of 8 residents reviewed for MDS assessments in that: The facility failed to properly code Resident #25's quarterly MDS assessment a 3 for always incontinent instead of 9 for not rated since he had an indwelling urinary catheter. This deficient practice could result in missed or inaccurate care.

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 (Resident #95) out of 16 residents reviewed for care plans in that: The facility failed to ensure Resident #95 had a baseline care plan created within 48 hours when she was readmitted to the facility from the hospital. This deficient practice affects residents who are readmitted or new admissions and could result in decreased quality of care.

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 resident rights, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 1 of 8 residents (Resident #56) reviewed for care plans, in that: The facility failed to implement Resident #56's comprehensive person-centered care plan to address ADL self-care of eating. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to review and revise the comprehensive person-centered care plan for 2 (Resident #74 and #101) out of 16 residents reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #74's comprehensive care plan Interventions/Tasks were revised to reflect interventions taken after falls have occurred. 2. The facility failed to ensure Resident #101's comprehensive care plan was revised within the required timeframe. These failures could affect residents who are assessed and have care plans and places them at risk for not receiving necessary care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that a resident receives care consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1 (Resident #25) of 4 residents reviewed for pressure sore prevention and management in that: The facility failed to ensure Resident #25's heel protectors were on his feet during the 3 days of observations. This deficient practice affects residents at risk for skin breakdown and could result in pressure sores.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 ( Resident #25) out of 3 residents reviewed for indwelling urinary catheters in that: The facility failed to ensure Resident #25 had a leg strap to secure his indwelling urinary catheter tubing. The facility failed to ensure C NA B did not lift Resident #25's urinary catheter bag and tubing with urine in it above the resident's bladder when he assisted with incontinent care for the resident. This deficient practice affects residents with indwelling urinary catheters and could result in urinary tract infections and trauma to the stoma site.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure nurse aides can demonstrate competency in skills and techniques necessary to care for resident's needs, as identified through resident assessments and described in the plan of care for 2 residents (#25 and #92) of 2 residents observed for incontinent care and catheter care in that: 1. The facility faled to ensure C NA A did not wipe Resident #25's catheter tubing toward the site and not away to prevent contamination and C NA B raised the urinary drainage bag above the resident's bladder twice when turning him side to side. 2. The facility failed to ensure CNA B did not raide Resident #25's urinary drainage bag above the resident's bladder twice when turning him side to side. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to keep information that is resident-identifiable from the public for one Hallway (600) of 6 hallways observed and failed to maintain medical records in accordance with professional standards and practices for 1 resident (#25) out of 8 resident records reviewed in that: 1. The facility failed to prevent RN G from having identifiable resident information on top of her medication cart unattended. 2. The facility failed to ensure Resident #25's heel protectors were not initialed on his nursing MAR and that were never applied to his feet. These deficient practices could affect all residents whose records are maintained by the facility and could place them at risk for violation of privacy and errors in care and treatment.

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 2 ( Residents #228 and #244) of 7 residents observed for infection control in that: 1. The facility failed to ensure MA I did not pull plastic drinking cups from the side of her cart by sticking her finger in one pulling it apart from the others. MA I stacked up her medication cups with medications in them and carried them with her fingers around the rims when she brought them in to Resident #228. 2. The facility failed to ensure RN G did not contaminated the medication cup by placing her finger in the medication cup with medications prior to giving them to Resident #244. [...]

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 of 1 residents (Resident #1) reviewed for infection control in that: During Resident #1's incontinent care, CNA A did not perform hand hygiene between glove changes. This deficient practice could affect residents who require incontinent care and place them at risk for infection.