South Dallas Nursing & Rehabilitation

Inspectors wroteBased on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State in which practicing to provide activities for 1 of 1 facility reviewed for qualifications of activity professionals. The facility failed to ensure they had a qualified Activities Professional to direct their activities program. This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents (Resident #1) reviewed for supervision. Resident #1 walked out of the facility unattended and was missing from the building for approximately 24 hours on 05/16/26 at 7:00 PM to 05/17/26 at 6:50 PM. This failure could place residents at risk for Elopement.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for two rooms (Halls 100 and 600), exit glass doors on 3 of (100, 200, and 300) 6 facility resident halls and area between the kitchen and dining room reviewed for environment. The facility failed to ensure:- that there was not an accumulation of dust, debris, stains, and bacteria, creating an unsanitary, unkempt, exit room [ROOM NUMBER], 200, and 300 door plates; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen reviewed in that:1. The facility failed to ensure the floor drain was covered in the kitchen on 04/08/2026. 2. Gnats were observed in the kitchen on 04/08/2026.3. A rodent was observed coming out of the kitchen sink on 04/08/2026. The failures could place residents at risk for food born illnesses, infections, and possible hospitalization.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests.1. An anonymous resident reported observing a rodent in his room on 02/11/20262. Gnats and one rodent were observed in the during the kitchen inspection on 04/08/2026.3. Resident #3 reported observing rodents in his room on 04/07/2026.4. Kitchen observation on 04/08/2026 of a small mice/rodent exiting the kitchen sink that was covered with a clear plastic trash bag. The failures could result in residents having infections, exposure and inhalation of environmental substance, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe environment for residents, staff, and the public for one of two oxygen tanks observed for oxygen storage safety. The facility failed to securely store oxygen cylinders in the facility's one of two nurse's stations. This failures could affect the residents by placing them at risk of injury due to oxygen cylinders becoming unsecured and becoming a hazard.

Inspectors wroteBased on interviews the facility failed to ensure residents had the right to send and receive mail, and to receive letters, package and other materials delivered to the facility or the resident through a means other than a postal service, including the right to privacy of such communications for 6 of 6 residents (confidential residents) reviewed for resident rights. The facility failed to ensure staff distributed mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life. During a confidential resident group meeting 6 of 6 members in the group stated they never received mail on Saturdays because the Business Office didn't work on Saturdays but they did have a receptionist. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility failed to provide RN coverage for 8 consecutive hours daily for 10/19/24; 10/20/2411/16/24; 11/17/2412/07/24; 12/08/24; 12/14/24; 12/15/24; 12/21/24; 12/22/24; 12/28/24; 12/29/2401/04/25; 01/05/25; 01/11/25; 01/12/25; 01/18/25; 01/19/25; 01/25/25; 01/26/2502/22/25; 02/23/2504/19/25; 04/20/25; 04/26/25; 04/27/2505/03/25; 05/04/25; 05/10/25; 05/11/25; 05/17/25; 05/18/25; 05/24/25; 05/25/25; 05/31/2506/01/25; 06/07/25; 06/08/25; 06/14/25; 06/15/25; 06/21/25; 06/22/25; 06/23/2508/10/25; 08/16/25; 08/17/25; 08/23/25; 08/24/25; 08/30/25 08/3/2509/06/25; 09/07/25; 09/13/25; 09/14/25; 09/20/25; 09/21/25; 09/27/25; [...]

Inspectors wroteBased on interviews the facility failed to store food in accordance with professional standards for food service safety in the facility's only kitchen, reviewed for food safety,The facility failed to correctly label and date items in the dry storage and refrigerated areas. The facility failed to correctly label and date 4 bulk containers. These containers held flour, rice, breadcrumbs, and potatoes. There were no corresponding labels to indicate what the items were and when they were placed there and when they should be used by. The pantry had open packages of dry oats, breadcrumbs, and tortillas without the corresponding labels without the use by dates on the packages. There was no indication of when these items were opened and when the items should be discarded. These failures could place residents at risk for food-borne illness and cross contamination. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for two (Resident #5 and Resident #10) of five residents reviewed for PASRR Level 1 screenings. The facility failed to submit a new PASRR Level 1 screening when Resident #5 received a bipolar diagnosis. The facility failed to provide resident assessments to the habilitation coordinator within 20 days for Resident # 10. This failure could place residents at risk of not receiving necessary care and services to attain or maintain their highest practicable physical, mental, and psychosocial well-being. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for one (Resident #58) of ten residents reviewed for pharmaceutical services. 1. The facility failed to ensure that there was no expired insulin inside the medication room on 12/15/2025. 2. The facility failed to ensure LVN B did not put her personal beverage on the medication cart while passing medications on 12/15/2025. 3. The facility failed to ensure MA G did not put her personal beverage on the medication cart while passing medications on 12/15/2025. These failures could place the residents at risk of not receiving medications as ordered by the physician and potential interference with medication preparation.

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 infections for two of fifteen residents (Resident #34 and Resident #42) reviewed for infection control. 1. The facility failed to ensure CNA E performed hand hygiene during Resident #34's incontinent care on 12/15/2025. 2. The facility failed to ensure CNA D performed hand hygiene and changed her gloves during Resident #42's incontinent care on 12/15/2025. 3. The facility failed to ensure CNA F did not walk down the hallway wearing a gown and gloves on 12/15/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Halls 100 and 600) of 4 halls reviewed for environmental concerns. 1. The facility failed to ensure rooms' electrical outlets were covered in room [ROOM NUMBER] on hall 600. 2. The facility failed to ensure rooms were free from holes in the walls in room [ROOM NUMBER] on hall 600. 3. The facility failed to ensure windows were in a good state of repair in room [ROOM NUMBER] on hall 100. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant and unsafe. During an observation on 12/14/25 at 9:15 a.m., room [ROOM NUMBER] on hall 600 had an outlet that did not have a cover, no wires exposed . [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one (Resident #23) of eight resident reviewed for quality of care. The facility failed to ensure that LVN A used the proper procedures when providing wound care to Resident #23's diabetic ulcer on his right heel on 12/15/2025. This failure could place the residents with wounds at risk for infection or worsening of existing wounds.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for one (Resident #43) of sixteen residents reviewed for medication storage. The facility failed to ensure Resident #43 did not have a bottle of nasal spray on his side table on 12/14/2025. This failure could place the residents at risk of accidental overdose, misuse of medications, not receiving the medication's full therapeutic benefits, and possible side effects.

Inspectors wroteBased on interviews and record review the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for four of five dietary staff members reviewed for qualified dietary staff. The facility failed to ensure four (Cook A, [NAME] B, [NAME] C and Dietary Aide G) dietary staff members had their Texas Food Handler's License. This failure could place residents at risk of not having met their nutritional needs and place them at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and kitchen safety.1. The facility failed to ensure both handwashing sinks were in proper working order.2. The facility failed to ensure drainage in the dishwashing room was in working order.3. The facility failed to ensure the kitchen remained free of bugs and insects (pests). These failures could place residents at risk for food-borne illness and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain the kitchen equipment in good repair for 1 of 1 range hood reviewed for safe operating equipment. The facility did not ensure the range hood in the kitchen was in good repair. This failure could place the staff and residents at risk of a fire and not having safe operating equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pest. The facility failed to ensure the kitchen was free of gnats and rodent droppings on 10/14/2025, 10/15/2025 and 10/16/2025. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure care plans were developed in consultation with the resident's representative for 1 of 4 residents (Resident #1) reviewed for Comprehensive Care Plan in that:The facility failed to ensure Resident #1, or the resident's representative were invited to participate in the resident's care plan meeting. This failure placed residents at risk for a loss of independence, psychosocial well-being, and the opportunity for them to participate in the planning of their care.

Inspectors wroteBased on interviews and record review, the facility failed to notify the resident's representative when there was an incident resulting in injury for 1(Resident #2) of 4 residents reviewed for notification of changes. The facility failed to notify Resident 2's representative when resident fell from his bed causing delayed swelling to his face and arm. This failure could place residents at risk of not receiving the support and advocacy of their families after an incident.

Inspectors wroteBased on interview and record review, the facility failed to have evidence that all allegations of abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 1 of 5 residents (Resident #4) reviewed for abuse and neglect. The facility did not thoroughly investigate an incident in which Resident #4 made a grievance that a staff member was rough with her and did not stop perineal care when requested. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for one (Residents #3) of four residents reviewed for dental services. The facility failed to promptly, within 3 days refer Resident #3 with lost or damaged dentures for dental services. This failure could affect residents by placing them at risk for oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on interviews, observations and record review, the facility failed to ensure 3 (Resident#1, Resident#2 and Resident#3) of 4 residents care plans included services provided to the residents The facility failed to provide Resident#1,2, and 3, with care plans that reflected the intervention of a wander guard for residents. This failure could affect how to meet the resident's needs.

Inspectors wroteBased on interviews, observations and record reviews, the facility failed to ensure 2 out of 4 residents (Resident#1 and Resident#2) received adequate supervision and assistance devices to prevent incidents. The facility failed to ensure Resident #1 and Resident #2's wander guards worked properly. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, and deprivation of goods and services for 1 of 3 residents (Resident #1) reviewed for neglect. 1. The facility failed to provide Resident #1 with services for pain assessments from 02/10/25 to 02/21/25 which resulted in Resident #1 not being diagnosed with a fracture to his left humeral bone for 11 days. 2. The facility staff failed to report a fall to the administrative staff which resulted in Resident #1 not receiving an x-ray from 02/10/25 to 02/21/25. 3. The facility failed to make an appointment for Resident #1 as ordered by a hospital physician to be seen by an orthopedic surgeon from 02/22/25 to 06/07/25. An Immediate Jeopardy (IJ) situation was identified on 06/02/25. [...]

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 and each resident received adequate supervision and assistance devices to prevent accidents for one of 3 residents (Resident #1) reviewed for transfers. The facility failed to ensure that CNA A and LVN B transferred Resident #1 using a gait belt as per facility protocol, and dried the resident off before transfer, which resulted in a fall and a comminuted fracture (a fracture where the bone breaks into three or more pieces) to the left humeral neck (top part of the arm bone) and fractures to the glenoid bone (where the head of the arm bone connects to the shoulder), which were discovered from X-Ray results on 02/21/25. An Immediate Jeopardy (IJ) situation was identified on 06/02/25. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the designated interdisciplinary team member was responsible for collaborating with hospice representatives and coordinating LTC facility staff participation in the hospice care planning process for those residents receiving these services and communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family for 1 (Resident #1) of 8 residents reviewed for hospice services. The facility failed to ensure a staff member was designated to communicate with a hospice agency. This deficient practice could place residents at risk of receiving substandard care due to miscommunication between their hospice and facility caregivers.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 3 of 3 resident rooms (rooms 603, 605 and 607) and 1 of 6 hallways (600 hallway) reviewed for environment. 1. The facility failed to ensure the main hallway was free of roaches on 06/07/25 at 1:30 PM. 2. The facility failed to ensure resident rooms 603, 605 and 607 were free of rodents on 06/05/25 at 10:04 AM. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live.

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 and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administrator of the facility and to other officials which included the State Survey Agency in accordance with State law through established procedures for 1 of 8 residents (Resident #1) reviewed for reporting allegations of neglect. The facility failed to ensure a report for an allegation of neglect was submitted within 2 hours to the State Agency after Hospice RN D reported a fall with possible injury to LVN E. [...]

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 two residents (Resident #1 and Resident #2) of four residents reviewed for pharmaceutical services in that: 1. The facility failed to administer pain medications to Resident #1 as ordered upon admission after the resident requested pain medication on 1/23/2025. The facility also failed to return and administer Trazodone to Resident #1 as ordered on 1/24/2025. 2. The facility failed to acquire, administer, and accurately document two scheduled doses of gabapentin on 1/24/25 to Resident #1 as ordered. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident had the right to make choices about aspects of his or her life in the facility that were significant to the resident for one (Resident #1) of seven residents reviewed for self-determination. The facility failed to promote Resident #1's self-determination by not honoring his choice to receive medications at a later time on 1/24/2025. This failure could place residents at risk for poor self-esteem and decreased self-worth due to their needs and preferences not being met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for one (Resident #3) of 66 residents reviewed for assistive devices. A portable heater was found in use in Resident #3's room without direct supervision. This failure could place residents at risk for accidents or injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 (Resident #1) of 5 residents reviewed for quality of care. The facility failed to follow physician orders for daily fasting blood sugar checks for Resident #1 on 09/03/24, 09/04/24, 09/09/24, 09/10/24, 09/15/24, and 09/16/24. This failure could place the resident at risk of not receiving the care intended by the physician.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 (Resident # 8) of 5 residents' rooms and for 1 of 1 shower rooms reviewed for environment. 1. The facility failed to repair the wall in Resident #8's bathroom for at least a year. 2. The facility failed to ensure the shower room was sanitary, clean, free of foul odors, and in good repair. This failure could place 56 residents using the shower room and Resident #8 at risk of psychosocial harm and feeling uncomfortable due to living in an environment that was not homelike.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for one sharps container in the shower room of Hall 300 of three sharps containers reviewed for accidents and hazards. The facility failed to ensure that residents did not have unsupervised access to used razors in the shower room on Hall 300, and that the sharps container was monitored and changed out before it became overfilled. This failure could place residents at risk of lacerations and injury from used sharps.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for 1 of 1 medication room reviewed for pharmacy services. The medication room contained: 1. 1 almost full opened box (quantity of 50) of IV administration sets with an expiration date of 6/05/2024. 2. 10 IV insertion cannulas with an expiration date of 02/28/2024. 3. 6 acetaminophen 650mg suppositories with a use by date of 12/11/2023 prescribed for Resident #30. This could place 1 (Resident #99) of 1 resident receiving IV medications and Resident #30 at risk for not receiving the intended therapeutic benefit of their medications and having possible adverse effects.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents and staff for 1 handwashing sink, 1 dishwashing sink and 1 dishwasher reviewed for essential equipment. 1. The facility failed to ensure the handwashing sink was in working order 2. The facility failed to ensure drainage in the dishwashing sinks was in working order. 3. The facility failed to ensure drainage in the dishwashing room was proper working order. These failures could affect all residents that eat meals from the kitchen and pose a possible risk for cross-contamination.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free from pests for one of one active shower rooms reviewed for pest control program. The facility had live small flies and roaches in the only active shower room in the facility. This failure could place residents at risk for spread of infection, cross contamination, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced each resident's respect and dignity for 2 Resident's (Resident #49 and #57) of 5 residents reviewed for dignity. The facility failed to provide dignity and respect for Residents #49 and #57 by leaving the Residents' privacy bags off their foley bags exposing the full urinary bag to the doorways. This failure placed residents at risk for embarrassment and low self-esteem.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure they had promptly notified the ordering physician, physician assistant, nurse practitioner, or clinical nurse specialist of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #28) of 10 residents reviewed for Keppra (antiseizure medication) lab levels and notifications. Resident #28 had abnormal Keppra lab results on 8/27/24, and the facility failed to follow up to ensure prompt notification was received by the ordering physician. This failure could result in the physician not being fully aware of the resident's clinical condition and response to Keppra for 10 residents currently prescribed Keppra.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from neglect for two of nine residents (Residents #1 and #2) reviewed for elopement. 1. The facility failed to ensure Resident #1 did not elope from the facility. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility as 2-hour monitoring was not completed properly. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train. 2. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibited and prevented abuse and neglect for two of nine residents (Resident #1 and Resident#2) reviewed for elopement. 1. The facility failed to follow the policy and procedure for neglect which allowed Resident #1 to elope from the facility. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility as 2-hour monitoring was not completed properly. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents receives adequate supervision and assistance devices to prevent accidents for two of nine residents (Resident #1 and Resident #2) reviewed for elopement. 1. The facility failed to ensure Resident #1 was adequately supervised to prevent him from leaving the facility. Resident #1 had access to the door code for the front door although he had impaired cognitive function or thought processes related to Dementia and lacked safety awareness. Resident #1 eloped from the facility on 05/14/23 and was arrested the same day 3.5 miles away for impeding the progress of a southbound public train. 2. The facility failed to ensure Resident #2 was supervised adequately and did not elope from the facility. Resident #2 was found lying on the ground at the transfer station for 30 minutes prior to EMS arrival. [...]

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 three of three residents (Residents #2 and #1) reviewed for ADL care. The facility failed to ensure Residents #2 and #1 bathed/showered three times a week as per their shower schedule. This failure could place residents at risk of skin breakdown, infection and loss of self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for one of five residents (Resident #2) reviewed for privacy. The facility failed to ensure LVN E locked the computer, which showed Resident #2's wound care information, after she walked away and left the computer unattended. This failure could place residents at risk of having medical information exposed to others, and cause residents to feel uncomfortable and disrespected.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for one of five residents (Resident #2) reviewed for storage of medication. The facility failed to ensure a 0.9% sodium chloride syringe was not stored at Resident #1's bedside table and failed to ensure it was secured in the medication cart or medication room. This failure could place residents at risk of medication misuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for one of twelve rooms (room [ROOM NUMBER]) reviewed for pests. The facility failed to ensure an effective pest control program was implemented to prevent the presence of gnats in room [ROOM NUMBER]. This failure could place residents at risk for the potential spread of infection, cross-contamination and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the nurse staffing information was posted on a daily basis for one of twenty-one days (05/17/24) reviewed for nursing services and postings. The facility failed to update the posting of the daily staffing information on 05/17/24. This failure could place residents at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 16 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on. 02/05/24 (Monday); 02/06/24 (Tuesday); 02/07/24 (Wednesday); 02/08/24 (Thursday); 02/09/24 (Friday); 02/12/24 (Monday); 02/13/24; (Tuesday); 02/15/24 (Wednesday); 02/16/24 (Thursday); 02/17/24 (FR); and 03/07/24 (Thursday) This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for three (Halls 100, 400 and 500) of six halls and one (main dining room) of two dining rooms and one of one kitchen and one (facility entrance) of one reviewed for environment. (A)The facility failed to ensure the exit door on the 100 hall and front of Resident #5's room door was clean and in good repair. The facility failed to ensure the floors on halls 100, 400 and 500 were clean and in good repair. The facility failed to ensure the flooring in the dining room next to the kitchen entrance and ice machine was clean and in good repair. The facility failed to clean or replace the two rusty panic bars on hall 100 and 2 rusty panic bars on hall 500. The facility failed to ensure Resident #9's room was cleaned thoroughly. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for two (Residents #1 and #2) of six residents' rooms reviewed for Environment. The facility failed to ensure Residents #1 and #2's bathroom floors and walls were in good repair and sanitary. These failures could place all residents at risk of falls which could result in injuries leading to a decreased quality of life and psycho-social well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests for three (Halls 300 and 400 hall) of five halls and 1 (300-hall shower room) of 4 shower halls reviewed for pest control program. The facility had dead roaches and gnats in areas of the facility including the nurse's station, Halls 300, 400 and the shower room. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life. Findings Include: Observation 03/07/24 at 9:10 a.m., revealed 3-4 live gnats flying in the entrance of 300 hallway near the shower room. Observation on 03/07/24 at 9:18 a.m. 9-10 live gnats were observed in room [ROOM NUMBER] Resident bathroom, 1-3 live gnats were noted to be flying in the room . [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to treat residents with respect and dignity for one (Resident #3) of six residents reviewed for Resident rights. The Nursing staff failed to ensure Resident #3 did not have food and drink stains on his shirt for over three hours on 03/07/24. This failure could affect residents who require assistance with meals, which could cause their food and drinks to fall onto their clothes, resulting in a sense of diminished self-worth and psycho-social well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to thoroughly investigate an allegation of abuse for 1 resident (Resident #1) of 5 residents reviewed for abuse and neglect. The facility failed thoroughly investigate an allegation of abuse and neglect for Resident #1. This failure could place all residents at risk of abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 5 (Residents #1, #7, #12, #17, and #20) of 38 residents observed for wheelchairs. The facility failed to properly maintain wheelchairs for Residents #1, #7, #12, 17 and #20. The wheelchair arm rest pads were torn and cracked with exposed interior foam. The arm rest pads could not appropriately be cleaned due to the cracked and exposed foam. These failures could place residents at risk for diminished quality of life and at risk for skin issues and discomfort due to the lack of a well-kept wheelchairs.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 16 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on. 02/01/23 (WE); 02/02/23 (TH); 02/03/23 (FR); 02/06/23 (MO); 02/07/23 (TU); 02/08/23 (WE); 02/09/23 (TH); 02/10/23 (FR); 02/13/23; (MO); 02/14/23 (TU); 02/15/23 (WE); 02/16/23 (TH); 02/17/23 (FR); 02/20/23 (MO); 02/21/23 (TU); 02/27/23 (MO) This failure could place residents at risk of missed nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that medications were secure and inaccessible to unauthorized staff and residents for one of one treatment cart reviewed for prescribed treatment medication storage. The facility failed to ensure treatment supplies were secured or attended by authorized staff when RN D's and LVN E's treatment cart for the facility hallways 100, 200, 300, 400, and 500 was left unlocked. This failure could result in resident access and ingestion of prescribed treatment medications leading to a risk for harm and possible drug diversion.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for five (Residents #10, #12, #18, #40 and #44) of seven residents reviewed for infection control in that: LVN B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #10, #44. LVN C failed to disinfect the glucometer machine (an instrument for measuring the concentration of glucose in the blood) and the blood pressure cuff in between resident use, for resident #12, #18, and #40. This failure could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for three (Hall 100, 200, and 300) of five halls observed for environment. The facility failed to ensure resident's bathrooms on Halls 100, 200, and 300, were clean, safe, and in good repair. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment and equipment.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility reviewed for pests in that: Flies and gnats were observed in multiple areas of the facility. This failure could affect residents by placing them at an increased risk of exposure to pests and vector-borne diseases and infections.

Inspectors wroteBased on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and kitchen safety. 1. The facility failed to ensure items in the kitchen and dry storage were labeled and stored in accordance with the professional standards for food service. 2. The facility failed to ensure the handwashing sink#1 of 2 was free from leaking/running water. 3. The facility failed to ensure the kitchen remained free of bugs and insects (pests). 4. The facility failed to ensure both handwashing sinks were in working order. 5. The facility failed to ensure drainage in the dishwashing room was proper working order. 6. The facility failed to ensure that the 4-outlet plug in kitchen, over main prep area, were all 4 fully functional. [...]