San Antonio West Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure incontinent care was provided in accordance with appropriate treatment and service practices to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinent care and catheter care, in that: While providing incontinent care for Resident #2, CNA B used a back to front motion to clean Resident #2. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

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 5 residents (Resident #7) reviewed for infection control, in that: The facility failed to ensure CNA B changed her gloves and sanitized her hands after cleaning Resident #2 and before touching the clean brief and used the proper technique to sanitize her hands. 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 residents have a right to personal privacy for 1 of 2 residents (Resident #2) reviewed for resident rights, in that: CNAs A and B did not completely close Resident #2's privacy curtain while providing incontinent care for the resident. This deficient practice could place residents who received incontinent care at-risk of loss of dignity, embarrassment, and a decline in quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for physical environment. The facility failed to ensure the facility was free from flies. These failures could lead to cross contamination and/or decreased quality of life. Based on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests for 1 of 1 facility reviewed for physical environment. The facility failed to ensure the facility was free from flies. These failures could lead to cross-contamination and/or decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with accepted professional standards of practices, maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 3 of 6 residents (Resident #6, Resident #7, and resident #8) reviewed for clinical records. The facility failed to accurately document on 28 medication administrations for Resident #6, Resident #7 and Resident #8 the holding of a blood pressure medication due to residents' blood pressure being out of parameters. The documentation shows the medication was administered despite parameter orders stated to hold the medication. This failure could place residents at risk of not receiving care and services needed or alteration to medication dosing by physicians due to inaccurate information being documented.

Inspectors wroteBased on observations and record reviews the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representatives when there was an incident involving the resident and has the potential for requiring physician intervention; a need to alter treatment for 2 of 17 Residents (Resident #1 and #2) reviewed for incident reporting. 1. The facility failed to report to Resident #1's Representative and Resident #2's Representative an incident of Resident #1 found partially disrobed in Resident #2's room on 4/14/26.2. The facility failed to report to Resident #1's Physician and Resident #2's Physician an incident of Resident #1 was found partially disrobed in Resident #2's room on 4/14/26. This failure could place residents at risk for delayed responsible party and physician's intervention.

Inspectors wroteBased on interviews and record reviews the facility failed to report all alleged violations involving abuse, neglect, exploitation or mistreatment, 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 2 of 17 (Residents #1 and #2) residents reviewed for reporting. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to have evidence that all alleged violations are thoroughly investigated, prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress, report 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, for 2 of 17 Residents (Resident #1 and Resident #2) reviewed for facility investigations. The facility failed to investigate allegations of incident of Resident #1 found partially disrobed in Resident #2's room. This failure could place residents at risk for not having allegations of ANE investigated and summary reported.

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 were identified in the comprehensive assessment. The comprehensive care plan must describe the following; the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being and the services provided or arranged by the facility, as outlined by the comprehensive care plan, must be culturally-competent and trauma-informed, for 2 of 17 Residents (Resident #1 and Resident #2) reviewed for comprehensive care plans. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide or obtain laboratory services that meet the needs of its residents, for 1 of 3 residents (Resident #4) reviewed for laboratory services, in that: LVN G failed to obtain a urinary analysis for resident #4 as prescribed by NP H. This failure could place residents at risk for delayed treatment. Based on interviews and record reviews, the facility failed to provide or obtain laboratory services that meet the needs of its residents, for 1 of 3 residents (Resident #4) reviewed for laboratory services, in that;. LVN G failed to obtain a urinary analysis for resident #4 as prescribed by NP H. This failure could place residents at risk for delayed treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for four (4) of seven (7) residents (Resident #5, Resident #11, Resident #57, and Resident #86) reviewed for resident rights. 1. The facility failed to obtain signed consent for psychotropic (a medication that affects brain function and used to treat psychiatric conditions) mood stabilizer medication, Divalproex Sodium (Depakote) which was administered to Resident #5. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain a sanitary, orderly, and comfortable interior by housekeeping and maintenance services, which were necessary to maintain a sanitary, orderly, and comfortable interior for 4 of 8 resident rooms (room [ROOM NUMBER], 6, 11, and 13) and 1 of 1 hallway of the secured unit reviewed for homelike environment. The facility failed to ensure resident room [ROOM NUMBER] in the secured unit had repaired the door frame with dents, cracks, black scuff marks, wall with peeled paint, worn out paint, torn furniture, chipped baseboard trim lifting from the wall, light fixture with plastic border loose and hanging, windowsill cracked, peeling paint, missing caulking. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 3 of 10 residents (Resident #10, Resident #15, Resident #82) reviewed for care planning. The facility failed to ensure Resident #10's comprehensive care plan included safety interventions related to the use of an electronic cigarette (vape). The facility failed to ensure Resident #15's comprehensive care plan included elopement risk and safety interventions related to placement in a secure unit. The facility failed to ensure Resident #82's comprehensive care plan included elopement risk and safety interventions related to placement in a secure unit. This failure could place residents at risk of inappropriate use of the device resulting in injury or not receiving appropriate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 2 of 5 residents (Residents #95 and #89) reviewed for medication administration. The facility failed to ensure Resident #95 received his anti-seizure medication as ordered by the physician on 4/9/2026. The facility failed to ensure Resident #89 received the correct dose of insulin on 4/10/2026. These failures could result in residents not receiving the intended therapeutic effects of medications, including seizures or low blood sugar levels.

Inspectors wroteBased on observation, interview, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for one (1) of one (1) kitchen (Kitchen 1) reviewed for food safety requirements. 1. Food service staff failed to ensure an internal thermometer was present in the reach-in refrigerator #1. 2. Food service staff failed to ensure a facility contracted food supplier representative wore hair restraints while in the kitchen during meal preparation. 3. The facility failed to ensure a package of pork ribs was labeled and dated in the walk-in freezer. 4. [NAME] P failed to ensure the walk-in freezer temperature log was filled out for the morning of 04/07/2026. These failures could place residents at risk for the spread of infections, food contaminations, food-borne illnesses, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the secured unit in the facility was free of pests and rodents. The facility failed to ensure the building was free of insects. This failure could lead to contamination and/or 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 needs and preferences for one (1) of seven (7) residents (Resident #77) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #77's room was in a position accessible to the resident on 04/07/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's care planning for 1 of 3 residents (Resident #16) reviewed for PASARR services. The facility failed to ensure Resident #16's PASRR Level 1 Screening was completed accurately with mental illness diagnosis to secure a Level 2 Evaluation by the Local Authority. This deficient practice could place residents at risk of not receiving services identified by the local authority.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles for 1 of 3 medication carts (A- hall medication cart) reviewed for medication storage. The facility failed to ensure a vial of insulin was labeled with the expiration date. This failure could result in residents receiving expired medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received therapeutic diets that were prescribed by the attending physician for 1 of 21 residents (Resident #2) reviewed for therapeutic diets. The facility failed to ensure Resident #2 received large protein portions instead of large portions at every meal per RD recommendations, which were approved by Dr. Q.This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: Record review of Resident #2's admission record, dated 04/07/2026, reflected resident was a [AGE] year-old male, initially admitted [DATE] and re-admitted [DATE] with diagnoses to include type 2 diabetes mellitus with hyperglycemia (elevated blood sugar levels due to the body's inability to self-regulate levels), onset date 01/29/2026. [...]

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for one (1) of one (1) residents (Resident #14) reviewed for hospice services. The facility failed to maintain the current hospice plan of care to ensure Resident #14 received adequate end-of-life care. This failure could place residents at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.

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 6 residents (Resident #89) reviewed for infection control. The facility failed to ensure LVN C utilized proper PPE when administering insulin to Resident #89. This failure could result in the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to provide personal privacy during personal care for 1 of 6 Residents (Resident #1) who were reviewed for care. CNA A failed to ensure Resident #1 was not exposed to anyone passing his room when she opened Resident #1's door during care. This deficient practice could place residents at risk for feeling embarrassed and compromise the resident's dignity.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and If necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 1 Resident (Resident #2) who was reviewed podiatry care. Nursing staff failed to ensure they cut Resident #2's toenails and/or that they referred Resident #2 to a podiatrist for care as needed. This failure could place residents at risk of experiencing pain when wearing footwear or poor hygiene.

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 environment to help prevent the development and transmission of communicable diseases and infections for 1 of 1 Resident (Resident #1) who was reviewed for infection control. CNA A failed to wear a mask and gown while providing Resident #1, who was on EBP, with peri-care. This deficient practice could place residents at risk for contracting infectious diseases.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 1 of 1 Resident (Resident #3) reviewed for smoking. The facility failed to ensure Resident #3 smoked in the facility designated smoking area. Resident #3 was smoking in the front patio area of the facility. This deficient practice could place residents at risk of avoidable accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and 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 needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 of 9 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for care plans. 1. The facility failed to ensure Resident #1's care plan included his having exhibited physical aggression toward another resident. 2. The facility failed to ensure Resident #2's care plan included his having experienced physical aggression from another resident. 3. [...]

Inspectors wroteBased on Observation, 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 1 (Resident #5) of 9 residents reviewed for medical records. The facility failed to ensure Resident #5's electronic medical diagnosis list accurately indicated the resident had dementia with anxiety on the list, but the physician note indicated, the resident had dementia with anxiety. This failure could place residents at risk for missed treatment and medications which could result in a decline in health and well-being.

Inspectors wroteBased on observation, 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 #2) reviewed for accuracy of medical records. Resident #2 did not have foley catheter orders in Resident #2's November 2025 administration orders when he readmitted from the hospital with a foley catheter on 11/03/2025. 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's guardian 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 of being displaced without notice and/or reason to accommodate other individuals.

Inspectors wroteBased on observation, interview and record review, the facility failed to consult with the resident's physician and notify the representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for one of eleven residents (Resident #2) reviewed for quality of care. The facility failed to notify Resident #2's resident representatives of Resident #2's increase of exit seeking behavior with refusal for redirection resulting in police intervention observed on 10/03/2025. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for two of eleven residents (Resident #1 and Resident #3) reviewed for care plans. 1. The facility failed to update or add interventions to Resident #1's care plan regarding behaviors that impact his safety, stripping the bed and the suspected behavior of repeatedly pulling on the privacy curtain resulting in pulling the curtain track down from the ceiling. 2. The facility failed to update or add interventions to Resident #3's care plan regarding reported suicidal ideation that occurred on 10/05/2025. These failures could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assist in offering nutrition and hydration based on the residents comprehensive assessment. The facility failed to ensure the resident was offered a therapeutic diet and prepare and serve food in a form to meet individual resident's needs for 1 of 6 residents (Resident #1) reviewed for dietary requirements. The facility failed to ensure residents received their prescribed therapeutic diet. This deficient practice could result in residents losing weight, feeling abnormally hungry or weak and a reduced quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that it was free of pests and rodents for 1 of 7 residents (Resident #1) reviewed for pest control program. The facility failed to ensure Resident #1 was not found with maggots in his right stage 3 heel wound on 10/16/25. Resident #1 refused an ER referral when the maggots were found and was sent to the emergency room a day after the maggots were discovered. An IJ was identified on 10/23/25. The IJ template was provided to the facility on [DATE] at 3:25 p.m. While the IJ was removed on 10/25/25, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with potential for more than minimal harm that is not immediate jeopardy because the facility's need to monitor the implementation and effectiveness of its Plan of Removal. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure ulcers. The facility failed to implement treatment orders for Resident #1's wounds for 5 of 9 wounds for 12 to 13 days; did not document on the TAR if treatment was provided to 5 of 9 wounds for 13 days; and did not complete a weekly wound assessment on 10/09/2025 for 5 of 9 wounds. This failure could hinder the healing of the residents' existing pressure ulcers or lead to the development of additional skin injuries.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain medical records that were compete and accurately documented for 1 of 3 residents (Resident #1) reviewed during the complaint investigation. The facility failed to ensure that Resident #1's treatment administration record noted treatments on 8.13.2025, 8.18.2025, and 8.24.2025 as required by the orders noted on the electronic medical record. This failure could place residents at risk of not receiving necessary care and services or receiving care and services more often than ordered.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 5 residents (Resident #1 and #2), reviewed for functional environment. The facility failed to provide Resident #1's room with a functional overhead light fixture and an unbroken window blind. This failure could lead to residents experiencing a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide each resident that receives food from the kitchen, food that is palatable, attractive and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for safe and appetizing temperatures: The breakfast meal served on 8/15/25 did not have the required holding temperatures for the last meal trayed served from the kitchen. This failure could lead to a diminished quality of life and expose residents to food borne pathogens and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service safety. The food temperature logs were incomplete. This failure could place residents who ate meals from the kitchen at risk for spread of infections, food contamination, and food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain dietary equipment that was in safe operation condition for 1 of 1 kitchen reviewed for steam table operation. The steam table was not operating. This failure could place residents who ate meals from the kitchen at risk for spread of infections, food contamination, and food borne illnessThe

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 4 residents (Resident #2 and Resident #3) reviewed for clinical records.1. The facility failed to ensure Resident #2's output was documented in his medical record on 6/9/25 and 6/19/25. 2. The facility failed to ensure Resident #3's output was documented in his medical record on 6/9/25 and 6/19/25. 3. The facility failed to ensure Resident #3's complete VS were documented in his medical record on 6/29/25. This failure could place residents at risk of not receiving the care and services needed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, and distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen observed for food service safety. The facility failed to have two overhead ceiling light covers in the cooking area free from numerous dead brown insects. The facility failed to ensure the ceiling vent in the dishwashing area was free from a black substance throughout the vent. These failures could place residents who eat meals from the kitchen at risk for spread of infections, food contamination, and food borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 16 rooms, reviewed for functional environment. The facility failed to provide Resident #1 with functional bedside and overhead lights for a minimum of 30 days. This failure could lead to residents experiencing a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to protect the residents right to be free from physical abuse by Resident #83 and #55, for 3 of 13 residents (Residents #55, #61, and #83) reviewed for physical abuse and neglect. 1. On 1/11/2025 on or about 11:00 AM Resident #61 was physically battered by Resident #83, to include a face punch, his hair pulled, and drug by his foot across the floor. 2. On 4/9/2024 Resident #61 entered Resident #55 room and began to use the restroom when Residents #55 and #61 began forcing each other's hands away from one another. 3. On 4/22/2024 Resident #61 was punched in the nose by Resident #55. 4. On 8/12/2024 Resident #61 was punched in the face by Resident #55 when he entered Resident #55's room. An IJ was identified on 1/29/2025. The IJ template was provided to the facility on 1/29/2025 at 3:15 PM. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure each resident was treated with respect, dignity, and care for 2 of 8 residents (Resident #18 and Resident #56) observed for resident rights. 1. The facility failed to ensure all residents were served at one table before serving the other tables, allowing all residents to eat at the same time at their respective tables. 2. Residents were served a fried chicken patty instead of fried chicken for 01/26/25 lunch meal. 3. Residents struggled to cut their fried chicken patty with a fork. These failures could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure and provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 5 of 8 (Residents #5, #22, #45, #67, #79) residents in that: 1. Resident #5 stayed in bed and had not observed activities program and activity assessment was not up to date. 2. Resident #22 she called bingo/loteria (Mexican bingo) and tried to get some activities for the other residents, since we don't have a full time Activity Director, since November 2024. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the activities program must be directed by a qualified professional who is a qualified therapeutic recreation specialist or an activities professional who- Is licensed or registered, if applicable, by the State in which practicing; and has completed a training course approved by the State for 1 of 1 facility in that: Operations Manager stated no full time Activity Director. No full time Activity Director since November 2024. This failure could result residents not having activities while residing in the facility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection for 3 of 8 (Resident #67, #5 and #45 ) residents in that: 1. Resident #67 had a pressure ulcer on her heel and was not observed offloading her heels. 2. Resident #5 had a pressure ulcer on her heel and was not observed offloading her heels. 3. Resident #45 was not turned every 2 hours by staff. This could affect all residents with pressure ulcers and could result in wounds not healing.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 8 of 16 residents (Residents #5, 20, #27, #38, #68, #69, #81, and #85) reviewed for pharmacy services. 1. On [DATE] Medication Aide E administered late medications to Resident #20 at 10:49 AM: a. Acetaminophen 325mg, (Tylenol) late by 1 hour and 49 minutes. b. Levetiracetam 500mg (a medication to treat seizures) late by 1 hour and 49 minutes. 2. On [DATE] Medication Aide E administered late medications to Resident #27 at 9:20 AM: a. Carvedilol 12.5mg (used to treat high blood pressure) late by 20 minutes. b. Divalproex 125mg (used to treat schizophrenia) late by 20 minutes. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5%, for 25 medication administration opportunities with 4 errors resulting in a 16% medication error rate, for 1 of 8 residents (Resident #62) reviewed for medication administration. 1. Medication Aide E administered Resident #62 his medication doxazosin (a medication to treat high blood pressure) 1 hour and 28 minutes late and his hydralazine (a medication to treat high blood pressure), carvedilol (used to treat heart failure with high blood pressure), and furosemide (used to treat swelling due to heart failure) late by 58 minutes. These failures placed residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to have drugs and biologicals used in the facility labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable; and the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, for 1 of 1 nurse medication carts reviewed for security and supervision and for 3 of 8 residents (Residents #5, #81, and #85) reviewed for safe storage of insulins. 1. On [DATE] at 6:06 PM LVN J attended the nurse medication cart on the facility's D-hall and left the medication cart unsupervised and unlocked for 7 minutes while she left and provided care for a Resident. LVN J was out of line-of-sight with the nurse medication cart. 2. [...]

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 1 kitchen reviewed, in that: 1. In a refrigerator, there were 2 bags of salad, 1 dated 01/25 and one not dated, and 1 bag of ham, dated 01/17, that did not reflect a discard date. 2. The facility's documents Three Compartment Sink Log and Milk Refrigerator Temperature Log for January 2025 reflected no entries were documented January 22-January 24. 3. Dietary Aide AG had a facial piercing and parts of her hair exposed while working in the kitchen. These failures could place residents who consumed meals and/or snacks prepared in the facility kitchen in danger of food-borne illness.

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; Standard and transmission-based precautions to be followed to prevent spread of infections; for 3 of 8 residents (Residents #45 and #69) and 3 of 3 staff (MA E, DON, LVN J) reviewed for infection prevention with Enhanced Barrier Precautions. 1. Resident #69 was diagnosed with a urinary tract infection (UTI), assessed with the need for infection prevention enhanced barrier precautions (EBP), and on 1/26/2025 at 11:52 AM the DON wore 1 glove for personal protective equipment (PPE) while attempting to administer an intravenous access for Resident #69. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 1 secured yard reviewed for safety. 1. Daily intermittent observations, from 1/26/2025 to 1/30/2025, revealed the facility's secured backyard and smoking patio yard had a section of chain link fence a section of the chain link fencing was detached from the top rail and leaning down. 2. Daily intermittent observations, from 1/26/2025 to 1/30/2025, revealed the facility's secured backyard and smoking patio yard had several red fire rated trash cans, designated for cigarette butts, filled with non-cigarette butt trash. These failures could place residents at risk for elopement and/or fire risks.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 3 of 9 (room [ROOM NUMBER], #47 and resident #76) incidences of privacy concerns in that: 1. LVN J did not knock on rooms [ROOM NUMBERS] before entering rooms. 2. LVN Z left her computer open with resident#76's personal information. This could affect and result in resident privacy being violated.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents had a safe, clean, comfortable, and homelike environment, with adequate and comfortable lighting levels in all areas; for 2 of 8 residents (Residents #18 and #37) reviewed for adequate lighting in the dining room. On 1/26/2026 at noon and ongoing until 1/30/2025 the facility's dining rooms had malfunctioning fluorescent lamps and fixtures, which residents #18 and #37 had stated they wished for better lighting during their meals. These failures could negatively impact residents' morale and overall sense of self-esteem.

Inspectors wroteBased on interview and record reviews the facility failed to ensure implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following -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 8 (Resident #5) residents in that: Resident #5's code status in chart did not match the care plan. This failure could affect residents by not having their end of life met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 resident wander guards (Resident #84) reviewed for accident hazards and supervision, in that: The facility did not ensure Resident #84's wander guard (a technology designed to prevent eloping from a facility) was working properly. This failure could place the residents at risk for elopement.

Inspectors wroteBased on interviews, and record reviews the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 8 residents (Resident #71) reviewed for nutrition. The facility failed to follow Resident #71's care plan for weighing Resident #71 weekly and failed to follow the facility's policy for weight assessment and intervention when Resident #71 had a significant weight loss. These failures could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow menus for 1 of 2 resident meals (dinner meal on 01/28/25) reviewed for menus in that: The facility failed to follow the menu for residents on soft bite sized and minced moist diets for the dinner meal on 01/28/25. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.

Inspectors wroteBased on observation, interview, and record reviews the facility failed to ensure each resident received adequate supervision to prevent accidents for 2 out of 8 residents (Resident #1 and Resident #2) reviewed for accidents and supervision, in that: 1. Resident #1 was an elopement risk and provided interventions to include a wander guard and checks to ensure proper placement. On 5/25/24 Resident #1 removed his wander guard and eloped from the facility. 2. Resident #2 was an elopement risk with interventions to include structured activity to distract from wandering. On 6/6/24, Resident #2 eloped from the facility. The noncompliance was identified as a PNC. The PNC IJ began on 5/25/2024 and ended on 6/6/2024. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for serious harm, disability, or death.

Inspectors wroteBased on observation, interviews and record reviews, the facility's governing body failed to designate a person to exercise the administrator's authority when the facility did not have an administrator and secure a licensed nursing home administrator within 30 days. The facility terminated Licensed Administrator A on 11/08/2024; hired Employee B, who was not a licensed administrator 24 days later and served in the capacity of the administrator for 39 days. This failure could result in a decrease in the quality of care provided to the residents that could result in potential minimal harm to the resident.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain documentation that an alleged violation was thoroughly investigated for 1 of 8 PIRs reviewed that involved (Resident #1 and Resident #2) for facility compliance to prevent further abuse from resident to resident altercations. The former Administrator A failed to investigate a resident to resident altercation (Resident #1 threw a cup and hit Resident #2 in the back of the head) that occurred on 07/21/2024. This failure could place residents at risk for abuse from altercations and could place the residents at risk of harm.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 2 residents (Resident #1) reviewed for dialysis. 1. The facility failed to ensure Resident #1 had a complete set of vital signs assessed prior to leaving for dialysis on (8) occasions. 2. The facility failed to ensure Resident #1 had a complete set of vital signs and access site assessed upon returning to the facility after dialysis on (9) occasions. These deficient practices could affect residents who receive dialysis treatments at risk for inadequate care and/or decline in health.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 8 residents (Resident #2, Resident #5, Resident #6, Resident #8, Resident #10, Resident #11, and Resident #15) reviewed for infection control. The facility failed to use proper infection control practices: 1. During skin assessment and wound care for Resident #2. 2. During skin assessments for Residents #5, #6, #8, #10, and #11. 3. During wound care for Resident #15. This failure could place residents at risk for infection and decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to immediately inform the resident, consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was a significant change in the resident's physical, mental, or psychosocial status in either life-threatening conditions or clinical complications for one of six residents (Resident #5) reviewed had a change of condition. The facility failed to notify the wound care physician, primary care physician, and Resident #5's resident representative of changes observed with Resident #5's wound, which resulted in the wound becoming an unstageable pressure ulcer (a wound that is covered by slough(debris that appears tan, yellow, green or brown in color) and eschar (hard plaque that is tan, brown or black in color). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one of six residents reviewed (Resident #5) for pressure ulcers. 1. The facility failed to ensure Resident #5 received services and treatment orders to prevent sacral and left heel pressure ulcers from developing. 2. The facility failed to notify the wound care physician or primary care physician of changes observed with Resident #5's wound, which resulted in the wound becoming an unstageable pressure ulcer (a wound that is covered by slough [debris that appears tan, yellow, green or brown in color] and eschar [hard plaque that is tan, brown or black in color]). [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #1) of 3 residents reviewed for enteral feeds, in that: The facility failed to ensure Resident #1's doctor's orders of administering water, before initiating feeding, were being followed. This failure could place residents at risk of not receiving the proper hydration requirements prescribed by the physician.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure that nurses were able to demonstrate competency in skills and techniques to provide nursing and related services for 1 of 3 residents (Resident #1) by 1 of 1 nurse (LPN F) reviewed for competent staff, in that: LPN F failed to provide water flushes for enteral nutrition before enteral formula was administered as ordered for Resident #1. This failure could place residents at risk for not receiving nursing services by adequately trained and licensed nurses and could result in a decline in health.

Inspectors wroteBased on interviews and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #1) of 4 residents reviewed for resident rights. The facility failed to notify Resident #1's physician of her change of condition on 8/08/2024 when an injury of unknown origin developed into a hematoma [collection of blood outside of a blood vessel where it does not belong, may result in swelling, discoloration and warmth] at the back of her head. Resident #1 was subsequently sent out to the hospital on 8/09/2024 . This failure could affect residents by placing them at risk for a delay in medical treatment, decline in health, and death.

Inspectors wroteBased on interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents for 1 of 4 residents (Resident #1) reviewed for medication administration, in that: The facility failed to administer Keppra (a medication used to treat seizures) to Resident #1 on 5/10/2024 in a timely manner and within the facility's medication window for administration. This deficient practice could result in a risk to the residents' health and complications which can lead to seizures.

Inspectors wroteBased on observations, interviews and records review, the facility failed to store, distribute, and serve food in a manner to prevent foodborne illnesses and food contamination for 1of 1 kitchen reviewed for: 1. Counters had an oily residue with a dark , oily substance on the edges and the crevices, and crumbs behind and underneath an appliance where food is prepared. 2. The stove had an oily black substance on and around the dials and black substance on the cooking surface, grill. 3. Desserts and cornbread were uncovered while waiting to be distributed, and while an insect was flying around the kitchen. 4. Two coffee carafes had dark brown substance inside the walls. 5. The floors had debris underneath the shelving units and underneath the sink there was a dead insect; and there was a very dark substance on areas of the floor and along the edges. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 9 residents (Resident #61) reviewed for quality of care in that: Resident #61 did not receive a neurologist appointment as ordered after a standalone seizure event occurring on or about 5/13/2023. This failure could affect residents who receive care from the facility and place them at risk for worsening conditions.

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 for 1 of 3 residents (Resident #50) reviewed for incontinent care in that: While providing incontinent care for Resident #50, CNA D did not clean Resident #50's meatus (duct by which urine is conveyed) working outward. This deficient practice could place residents at risk for infection and skin breakdown due to improper care practices.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents' right to reside and receive services in the facility with reasonable accommodations of residents needs and preferences for 1 of 5 residents (Resident #4) reviewed for accommodations of needs in that: Resident #4's call light was clipped out of reach onto his privacy curtain. This deficient practice could place residents at risk of not receiving care or attention needed.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 5 residents (Resident#4) reviewed for comprehensive care plans in that: The facility did not follow Resident #4's comprehensive care plan to ensure Resident #4's call light was within reach. This deficient practice could affect all residents and place them at risk for not receiving appropriate treatment and services or activities.