Schulenburg Regency Nursing Center

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a person-centered comprehensive care plan, consistent with the resident rights that included measurable objectives and timeframes to meet a resident's medical, physical, mental, and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 that was individualized to her care needs, which included ADLs, activities, specialized diet, dementia and related behaviors. This deficient practice could place residents at risk of not having their needs met to attain their highest practicable well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure 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. The facility failed to ensure that the medications stored in the medication storage room [ROOM NUMBER] were not expired. This deficient practice could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.

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 two of eight residents (Resident# 17, and Resident #92) reviewed for ADL care. The facility failed to ensure Resident #17's and Resident #91's nails were cleaned and did not have any rough edges. This failure could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure residents received care, consistent with professional standards of care to prevent development or promote wound healing for one ( Resident # 6 ) of 3 residents reviewed for pressure ulcers. The facility failed to perform Resident #6's thorough skin assessments on Sunday 03/08/2026 new skin issues to right gluteus (buttock), rear left thigh, and right fourth toe. These failures could place residents at risk for worsening skin concerns leading to discomfort, pain, and potential infections.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of two kitchens reviewed for kitchen sanitation. The facility failed to ensure Dietary Assistant [NAME] D used proper hand hygiene during food preparation. These failures could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #21 and Resident #87) of four residents reviewed for infection control practices, in that: The facility failed to ensure Med Aide C sanitized the blood pressure monitor before Resident #21, in between Resident #21 and Resident #87 and after Resident # 87 while obtaining blood pressure. This failure could place residents at risk for healthcare associated with cross-contamination and infections.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for one of two kitchens reviewed for kitchen sanitation. 1. The facility failed to ensure Dietary Assistant [NAME] A used proper hand hygiene during food preparation.2. The facility failed to ensure Dietary Assistant [NAME] A used appropriate oven mitt to remove food from the oven and prevent cross-contamination of the food. These failures could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #109) of 4 residents reviewed for elopement on 10/27/24. The facility failed to put interventions in place to prevent Resident #109 from eloping from the facility when she walked out of the memory care unit and exited the fire alarm gate on 10/27/24. Resident #109 was found by an exit door again on 12/01/24 . Resident has history of opening the doors after pushing on them for 15 seconds allowing the door to open. An IJ was identified on 12/12/24. The IJ template was provided to the facility on [DATE] at 3:30 PM. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan with resident rights, which included measurable objectives and time frames to meet the resident's mental and psychosocial needs for 3 of 10 residents (Residents #17, #41 and #98) reviewed for care plans. 1. The facility failed to update Resident #17's care plan to reflect current needs for suprapubic catheter care. 2. The facility failed to update Resident #17's care plan to reflect current needs with transfers. 3. The facility failed to update Resident #41's care plan to reflect current diet consistency orders. 4. The facility failed to update Resident #98's care plan to reflect current needs with transfers. This failure placed residents at risk of not receiving the appropriate care and services to maintain the highest practical well-being.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the residents rights to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 1 of 5 residents (Resident #26) reviewed for advanced directives. The facility failed to ensure Resident #26's out of hospital do-not-resuscitate (OOH-DNR) order form was signed by a physician. These failures could place residents at-risk of having their wishes dishonored or delay necessary medical treatment or intervention due to confusion.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be free from resident neglect for one (Resident #12) out of three residents reviewed for neglect. The facility failed to ensure FTA from ensuring the facility lift was located at the back facility door to transfer Resident #12 off the van onto the lift . Resident #12 fell from the van onto the lift located on the ground on 11/15/2024. This noncompliance was identified as PNC. The deficient practice occurred on 11/15/2024 and in-service was completed on 11/15/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of neglect, injury, and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 5 residents (Resident #38) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #38's Hydrocodone-Acetaminophen, a medication to help with pain. This failure could place residents at risk for not receiving prescribed medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 1 medication storage rooms reviewed for medications. The facility failed to remove 2 expired suppositories and 1 bag of expired medication from the medication storage room when it was observed on 12/11/24 at 12:50 PM. This failure could place residents at an increased risk of receiving expired and/or contaminated medications which could result in adverse health consequences.

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 3 of 12 residents (Resident #9, Resident #25 , Resident #102, ) observed for infection control. 1. The facility failed to ensure all staff donned PPE when entering rooms of residents' rooms who were on droplet precautions. 2. The facility failed to ensure PPE was adequately stocked for residents on droplet precautions. These failures could place residents at risk of cross-contamination and development of infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable state laws for 8 (Residents #1, #2, #3, #4, #5, #6, #7, and #8) of 9 residents reviewed for assessments. The facility failed to ensure the ADON had a current and active license. The ADON provided assessments to Residents #1, #2, #3, #4, #5, #6, #7, and #8 while her RN license was expired from [DATE] through [DATE]. This could place residents at risk for inadequate care and/or services.

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory electronic submission of staffing information based on payroll data in a uniform format. The facility failed to submit direct care staffing information on the schedule specified by CMS (Centers for Medicare and Medicaid Services), but no less frequently than quarterly for 1 of 3 quarters reviewed for payroll data information (Quarter 3 2023). The facility failed to submit PBJ staffing information to CMS for the 3rd quarter (April 1 - June 30) of fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

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 for two of four residents reviewed for catheter care (Resident #6 and Resident #30). A) The facility failed to ensure Resident #6's catheter was secured to her body with a catheter secure device per the care plan and physician's orders. B) The facility failed to ensure Resident 30's catheter was secured to his body with a catheter secure device per the care plan and physician's orders. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections.