Sorrento

Inspectors wroteBased on observation, interview, and record review, the facility failed to reasonably accommodate resident #1s needs and preferences by failing to ensure the call light was maintained within reach for 1 of 5 residents reviewed. This had the potential to affect the resident's safety and timely access to assistance. Based on observation, interview and record reviews the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodations of resident needs and preferenceshad the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 4 residents (Resident #1) reviewed for resident safety. [...]

Inspectors wroteBased on interview and record review, the facility failed to consider the views of the resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility or to demonstrate their response and rationale for such response for 1 of 1 resident council reviewed. The facility failed to follow up on concerns and requests expressed in resident council meetings September 2025 through November 2025. The facility failed to provide the resident council group with a response, actions, and rationale taken regarding their concerns. This failure placed residents at risk of not having their grievances followed up and addressed.

Inspectors wroteBased on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 5 (Resident #2, #44, #54, #136, #310) of 24 residents reviewed for MDS accuracy and completion. Residents #2, #44, #54, #136, and #310 did not have discharge MDS's completed. This failure could result in MDS inaccuracies.

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, the comprehensive person-centered care plan, and the residents' goals and preferences, for 1 of 3 residents (Resident #11) reviewed for dialysis services. The facility failed to complete Resident #11's post dialysis assessment on 8/4/2025, 8,6/20205, 8/8/2025, and 8/11/2025. This failure could place residents at risk for neglect by not being assessed and documenting the assessment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all licensed staff possessed the competency, and specific skill sets necessary to care for resident's needs for all nursing staff for 1 of 1 facility reviewed for competencies. The facility failed to ensure licensed nurses were appropriately updating Resident #12 for fall interventions when they were filling out the Nursing Fall Intervention Checklist. This failure could place residents at risk for harm due to staff who lack the appropriate skills, knowledge, and competencies to safely meet the residents' needs.

Inspectors wroteBased on record review, interview and observation, the facility failed to ensure that residents (1 of 1 facility) had suitable, nourishing meals and snacks outside of scheduled meal service times. The facility failed to ensure residents were offered snacks at bedtimes. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 8 residents (Resident #36) reviewed for resident rights. CNA M told Resident #36, just go in your brief and I'll come back to change you when Resident #36 asked to be taken to the restroom. This failure could place residents at risk for diminished quality of life, loss of dignity, and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to promote the resident's right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 (Resident #25) of 22 residents reviewed for advance directives, in that:Resident #25's OOH-DNR was not signed twice by all parties and was therefore invalid. This deficient practice could result in the resident's wishes regarding end-of-life treatment being dishonored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 1 of 8 residents (Resident #79) reviewed for environment. Resident #79's recliner's footrest was broken and had a metal piece sticking out of it. This failure could place residents at risk of a diminished quality of life due to an exposure to an environment that is unpleasant, unsanitary, or unsafe.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview, observation, and record review, the facility failed to ensure the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 (Residents #12) of 8 residents reviewed for care plans. The facility failed to implement fall interventions ( Lateral Supports as appropriate, initiated 08/13/25, Provide Reclining W/C as appropriate, initiated 08/13/25, Tilt Wheelchair, initiated 08/13/24, Raised Toilet Seat, initiated 08/13/25) from Resident #12's care plan. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #79) reviewed for medication administration. The facility provided Resident #79 with the medication Hydralazine HCl outside of physician parameters. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure all drugs and biologicals were stored and locked in compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 7 medication carts (800 hall medication cart) reviewed for safe and secure drug storage. The facility failed to ensure the 800-hall medication cart was secured and locked when LVN L utilized it and left it unlocked and unattended. This failure could place residents at risk for harm by accessing medications not prescribed for them, misappropriation, and not receiving the therapeutic effects of the medications as prescribed by their physicians.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the establishment and maintenance of 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 8 [KA1] (Resident #139) residents reviewed for infection isolation protocols. HK S failed to wear a N95 FFR while providing housekeeping services for Resident #139. This failure could place residents and staff at risk for harm by contracting and spreading the Covid-19 virus.

Inspectors wroteBased on interview and record review, the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 3 residents (Resident #1) reviewed for medical records. The facility failed to document all medications administered or withheld in the July 2025 MAR for Resident #1. This failure could place residents at risk of medication errors.

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 the resident rights set forth, 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 and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #6) reviewed for care plans 1. The facility failed to ensure CNA D and CNA E implemented Resident #6's care plan when they used a gait belt instead of a mechanical lift to transfer the resident. 2. The facility failed to ensure Resident #6 had her oxygen tubing on as care planned. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 2 (#6) residents in the 500 hall in that: Resident #6 was not transferred with Mechanical lift (Hoyer) during a transfer as care planned. This could affect all residents with Hoyer transfers and could result in accidents/injury. The Failures included: Record review of Resident #6's admission Record, dated 07/15/2025, she was [AGE] year documented a female resident who was admitted to the facility on [DATE] and re-admitted on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews failed to ensure the facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 18 (#6) residents with oxygen orders in that: Resident #6 was not wearing her oxygen tubing as ordered. This could affect all resident with Oxygen and could result in residents as ordered.

Inspectors wroteBased on observation, interview and record review the facility failed to provide special eating equipment and utensils for residents who needed them and appropriate assistance to ensure that the resident could use the assistance devices when consuming meals and snacks for 1 of 6 residents (Resident #7) reviewed for assistive devices. The facility failed to ensure Resident #7 had her 2 handed drinking cup as ordered. This failure could place residents at risk of a decrease in independence.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 of 9 residents (Residents #6) reviewed for abuse and neglect, in that: 1. CNA D observed CNA G yank Resident #6 out of bed and overheard CNA G tell Resident #6 he was going to kill him in Spanish. CNA D did not report the allegation timely and did not report to the Administrator. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the residents had a right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purposes of convenience, and not required to treat the resident's medical symptoms and to use the least restrictive alternate for the least amount of time and document ongoing re-evaluation of the need for restraints for 1 of 9 residents (Resident #6) whose care was reviewed in that: CNA G restrained Resident #6 by tying trash bags around Resident #6's wheelchair wheels to reduce Resident #6's independent mobility in the facility. This deficit practice could potentially affect residents who required wheelchairs for mobility evidenced by restricting movement, a decline in ADL function and psychological distress.

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 (Resident #1) of 4 residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #1's medications administered to him were consumed and were not left in the resident's room. 2. The facility failed to ensure Resident #1 received acetaminophen-hydrocodone 10/325 tablets as prescribed by a physician. These failures could place residents at risk for medication error and drug diversion.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 5 residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #1's acetaminophen-hydrocodone in the electronic medical record. This failure placed resident at risk for delayed or inaccurate medication administration which could result in decline in health and well-being.

Inspectors wroteBased on observations, interview and record review the facility's Dietary Services failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety. 1. The freezer in the kitchen had a packages of frozen foods that were opened and not sealed. 2. The ice machine had black substance that appeared to spread across in the area where ice was dispensed and hard water stains on the outside. 3. The ice machine in the nutrition room of the [NAME] Neighborhood had black substance on the hood of the unit where ice is dispensed. 4. The [NAME] neighborhood had food in the nutrition room in the freezer that was unlabeled. 5. In the dry storage area were gnats flying above the food. 6. There was a drainage trap with a plastic top for cups and paper near on the floor beneath the juice machines. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) 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 of 5 residents (Resident #96), reviewed for resident rights. The facility failed to notify Resident #96's resident representative of facility acquired pressure ulcers to his left foot, left lateral leg, left heel, right lateral knee, and left flank From 7/10/24 through 7/22/24 (12 days). This failure could place residents at risk of delays in decision making, and could cause anxiety, grief, and a poor quality of care and life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident#15) out of 24 residents reviewed for MDS assessments. Resident #15's quarterly MDS assessment with an ARD of 05/03/2024 inaccurately reflected he was ordered a therapeutic diet when he was ordered a regular diet. This failure could affect residents with MDS assessments and could result in inaccurate care.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for 2 (Residents#35 and #71) of 24 residents reviewed for care plans. 1. Resident #35's supra-pubic (above the pelvic bone) indwelling urinary catheter (tube inserted into bladder through abdomen) was not reflected in her (current) (undated) comprehensive person-centered care plan. 2. Resident #71's PASRR services was not reflected in his (current) (undated) comprehensive person-centered care plan. These failures could affect residents who reside at the facility and require care and result in missed or inaccurate care.

Inspectors wroteBased on observations, interviews, and record reviews 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 person-centered care plan to reflect the current condition for 2 of 12 residents (Resident #15 and Resident #70) reviewed for care plan revisions. 1. Resident #15's comprehensive person-centered care plan was not revised after his quarterly MDS assessment dated [DATE] to reflect he was ordered a regular diet instead of a therapeutic. 2. Resident #70's comprehensive person-centered care plan was not revised after his annual MDS assessment dated [DATE] to reflect he was on a therapeutic diet. This failure could affect residents with MDS assessments and could result in missed of required care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly within 1 of 4 medication carts (med cart in hall 100) observed for medication storage. RN B pre-poured medication for Resident #13 then stored it in the top drawer of the medication cart in hallway 100. This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications as ordered.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to dispose of garbage and refuse properly to ensure the residents were free from pests and rodents and to live in a safe and clean evironment. Garbage was observed on the ground with used incontinent briefs and other debris on the ground around the dumpsters. This deficient practice could cause the facility to have pests and rodents in and around the facility preventing a clean and safe homelike environment for the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were accurately documented for 1 of 5 residents (Resident #96), reviewed for administration. Wound assessments for Resident #96 were documented as the family was notified when they were not. This failure could result in confusion, decreased continuity of care, and result in anger, frustration, poor quality of life and a delay in decision making.

Inspectors wroteDuring observations, interviews, and record reviews, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents. In the dry storage area of the kitchen, about 5 gnats were observed flying around the food on the top shelf near packages of pasta and dry foods. This deficient practice could put residents at risks of food borne illness due infection control for the residents eating food from the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 5 residents (Resident #2) reviewed for advanced directives, in that: The facility failed to ensure Resident #2's Out-of-Hospital Do Not Resuscitate (OOH DNR) was honored. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure an admission policy was implemented for 1 of 5 Resident (Resident #2), in that: The facility failed to ensure Resident #2's RP was provided admission documents on admission. This deficient practice could place residents at risk who are not being informed of the admission requirements, services, and processes. Findings Include: Record review of Resident #2's face sheet, dated 7/19/24 revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnoses that included hemiplegia following nontraumatic subarachnoid hemorrhage affecting the left non dominate side (partial or total paralysis on one side of the boday after a brain bleed), cerebrovascular disease, and seizures. The advanced directive was blank on the face sheet. [...]

Inspectors wroteBased on interview and record review, the facility failed to incorporate the recommendations from the PASRR level II determination and the PASRR evaluation report into a resident's assessment, care planning and transitions of care for 1 of 2 residents (Resident #1) reviewed for PASRR. The facility failed to submit NFSS forms timely to the TMHP Long Term Care Portal for Resident #1 to ensure payment for specialized services throught the PASRR program. This failure could place residents at risk for not receiving specialized services in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed 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 of 1 newly admitted residents (Residents #2) reviewed for baseline care plan. The facility failed to ensure Resident #2's baseline care plan contained the correct code status. These deficient practices could place residents at-risk for decreased quality of life, improper care, and injury.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 1 of 5 residents (Resident #2) reviewed for accurate medical records in that: The facility failed ensure Resident #2's emergency contacts were updated and accurate. The deficient practices place residents at risk of misinformation about professional care provided.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and the resident's representative/s of the discharge and the reasons for the move in writing and in a language and manner they understand, failed to update the recipients of the notice as soon as practicable once the updated information became available, and failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 5 residents (Residents #1) reviewed for discharge. The facility failed to notify Resident #1's RP in writing and did not notify the State Long-Term Care Ombudsman by phone or in writing of Resident #1's discharge due to safety concerns. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility, causing a disruption in their care and services and potential decline in health.

Inspectors wroteBased on interview and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for one (Resident #1) of five residents reviewed for transfer/discharge. The facility failed to readmit Resident #1 to the facility after she was sent to the hospital on [DATE]. This deficient practice could place residents at risk of being discharged and not allowed to return to the facility, causing a disruption in their care and services and potential decline in health.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible for two of six residents (Resident #s 2 and 3), reviewed for accidents and hazards: The facility failed to ensure Resident #2 did not have 15 disposable razors stored in his restroom drawer and a pair of scissors. The facility failed to ensure Resident #3 did not have 5 disposable razors stored in his restroom drawer. These failures placed residents at risk of injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure 30-day discharge notices included a statement of the resident's right to appeal which included the name, address (mailing and email), and telephone number of the entity which receives such requests: and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request and name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman for 3 of 3 residents (Resident's #1, #2, and #3) reviewed for discharge. The facility failed to include in 30-day discharge notices to Resident's #1, #2, and #3 the email or address for the State Long-Term Care Ombudsman or the email address and phone number of the agency in which to file an appeal or instructions or information on how to file the appeal. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement an effective person-centered discharge plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 3 of 3 residents (Resident's #1, #2 and #3) reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #1's care plan included discharge planning and goals. 2. The facility failed to ensure Resident #2's care plan included discharge planning and goals. 3. The facility failed to ensure Resident #3's care plan included discharge planning and goals. These failures could affect residents and place them at risk of their discharge wishes not being honored and not receiving appropriate treatment and services on discharge:

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 8 staff (LVN A reviewed for staff qualifications. The facility failed to ensure LVN A renewed his nursing license before the expiration date in order to practice nursing in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly licensed

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were permitted to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility and failed to ensure a resident was not transferred or discharged while the appeal was pending for 1 of 3 residents (Resident #3) reviewed for discharges, in that: The facility failed to wait to transfer Resident #3 to another facility until he was out of Medicaid pending status. These failures could result in residents being discharged without appropriate notice and while they were waiting for approval from Medicaid could place residents at risk being discharged against their wishes.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 5 residents (Resident #4) reviewed for respiratory care in that: The facility did not ensure Resident #4's oxygen nasal cannula tubing (a small, flexible tube that contains two open prongs intended to sit just inside the nostrils) was dated, as ordered by the physician. This deficient practice could affect residents who receive oxygen therapy and result in infection and respiratory compromise.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents were seen by a physician for the resident's initial comprehensive visit for 1 of 5 residents (Resident #1) whose care was reviewed in that: Resident #1's initial comprehensive visit was not conducted by a physician. This deficient practice could affect residents and could lead to a decline in health status.

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 5 residents (Resident #3) reviewed for infection control in that: After cleansing Resident #3's perineal area, CNA D did not perform hand hygiene before applying Resident #3's clean brief. This deficient practice could affect residents and place them at risk for infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 1 of 2 resident (Resident #1) reviewed for assistance with ADL care, in that: The facility failed to prevent Resident #1 from missing scheduled showers between 10/20/2023 and 11/02/2023. The noncompliance was identified as PNC. The noncompliance began on 10/20/2023 and ended on 11/02/2023. The facility had corrected the noncompliance before the survey began. This failure could place residents who require assistance from staff for personal hygiene at risk of not receiving care and services contributing to overall poor hygiene, risk of experiencing a diminished quality of life, and possible skin infections.

Inspectors wroteBased on interview and record review the facility failed to ensure the notice to residents was provided when changes in coverage were made to items and services covered by Medicare as soon as reasonable possible was provided to 2 of 2 residents (Resident#42, and Resident #76) reviewed for Medicare/Medicaid. The facility failed to give Resident #42 and Resident #76 a Skilled Nursing Facility advance Beneficiary Notice (SNF ABN) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could affect residents who use skilled services and could place them at risk of not being aware of changes to provided services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 2 of 2 Residents (Residents #50 and #54) reviewed for transmitting assessments. 1. Resident #50's quarterly MDS assessment was not completed and transmitted within 14 days of completion. 2. Resident #54's death in facility MDS assessment was not completed and transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on observation, interview, and record review, 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 infection for 1 of 5 residents (Resident #47) reviewed for infection control, in that: CNA B failed to wash or sanitize her hands or change her gloves after touching the trash can and before starting catheter care. This deficient practice could place residents at-risk for infection due to improper care practices.