St. Giles Nursing and Rehabilitation Center

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 5 residents (Resident #3) reviewed for accidents hazards and supervision. -The facility failed on 06/28/2026 to prevent Resident #3 from falling due to CNA C leaving Resident #3 on her right side while attempting to change the draw sheets. This resulted in Resident #3 experiencing severe pain, being transported to the hospital and developing bruising to her left forehead, left eye, and left shoulder. These deficient practices could affect residents by injuring them during transferring and repositioning care.

Inspectors wroteBased on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the results of all investigations to the State Survey Agency within 5 working days of the incident for 3 of 3 residents (Residents #1, #2, #3) reviewed for records. -The facility failed on 05/28/2026 to thoroughly investigate a self-reported incident with an allegation of neglect for Resident #1 who was alleged to have been exploited for $2,000 by a family member.-The facility failed on 07/03/2026 to thoroughly investigate a self-reported incident within 5 working days of it being reported to the stated on 06/27/2026-The facility failed on 07/06/2026 to thoroughly investigate a fall that occurred on 06/28/2026 while CNA C was providing care to Resident #3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain evidence demonstrating the result of all grievances for a period no less than 3 years from the issuance of the grievance decision for 1 of 1 grievance binders reviewed. The facility failed to maintain evidence demonstrating the results of grievances from 04/14/26-05/08/26. This failure could place residents at risk of not having their grievances properly resolved, tracked, and documented for future review.

Inspectors wroteBased on interviews and record reviews, the facility failed to follow requirements of their written agreement with hospice agency indicating the facility would immediately notify the hospice about a significant change in the resident's physical, mental, social, or emotional status for 1 resident (Resident #2) of 1 reviewed for hospice care. The facility did not notify the local hospice agency of an as needed care plan meeting for Resident #2's significant change of condition in which Resident #2 was admitted to Hospice on [DATE]. The facility failed to implement a coordinated comprehensive person-centered care plan for Resident #2 when she was admitted to hospice on [DATE] for a significant change in condition. This failure could cause a decline in health for residents in hospice if the hospice agency is not notified of changes to their care plan.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 4 (Resident #2, Resident #46, Resident #62 and Resident #79) of 12 residents observed for oxygen management. The facility failed to properly bag and store an oxygen nebulizer for Resident #2, and Resident #46 The facility failed to clean the oxygen concentrator air filter for Resident #62 and Resident #79 while the oxygen was in use.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide safe and secure storage of medications for 3 of 4 medication carts (Halls E, B and C). 1. -The facility failed to ensure Blood Glucose Strips bottle was dated when opened according to manufacturer's specifications in two of two nurses' medication carts. 2. -The facility failed to ensure opened bottles of Liquid Protein Supplement was dated when opened according to manufacturer's specifications in two of two Med Aide's medication carts. 3. -The facility failed to ensure medication cart drawers were clean. 4. -The facility failed to ensure medication bottles stored in medication carts were free of dried dripping; staff were not storing personal care items removed from residents' rooms, discontinued medications and money in the medication carts.5. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation and food storage.-The facility failed to keep food containers stored in the dry storage room free of food particles.- The facility failed to ensure food stored in the dry storage room was properly stored, labeled, and dated.-The facility failed to keep liquid bottles stored in the dry storage room and refrigerator free of dried drippings and grease build-up.-The facility failed to keep the ice machine free of white calcium build-up. These failures could place residents who received meals and/or snacks from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on observation and interview the facility failed to post in a form and manner accessible and understandable to residents and resident representatives a list of names, addresses (mailing and email, and telephone numbers of all pertinent State agencies and advocacy groups, such as the State Survey Agency, the State licensure office, the protection and advocacy network, home and community based service programs, and the Medicaid Fraud Control Unit for 1 of 1 buildings reviewed for postings. The facility failed to ensure the number to HHS Long Term Care Regulatory (state survey and certification agency) number for filing grievances, or complaints or suspected violations of state or Federal violations was posted in an area where it was accessible to all residents and family members. [...]

Inspectors wroteBased on interview and record review , the facility did not ensure prompt efforts were made to document a resident grievance for 1 (Resident #65) of 9 residents reviewed for grievance resolutions. The facility failed to promptly document grievances regarding a complaint regarding customer service voiced by Resident #65 and Responsible Party. This failure placed resident at risk of not having their grievances resolved.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs for 1 resident (Resident #46) of 9 residents reviewed for care plans. The facility failed to ensure comprehensive person-centered care plan for Resident #46 addressed the use of the nebulizer under interventions. This failure could affect residents and put them at risk for not receiving care and services to meet their needs. Findings Included: Record review of Resident #46's admission record revealed a [AGE] year-old female with an original admission date of 12/28/2023 and a readmission date of 04/27/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 3 (Residents #29, #57 and #93) of 18 residents reviewed for foot care. The facility failed to ensure Resident #29, Resident #57, and Resident #93 who required assistance with ADLs, did not have long and dirty fingernails. The facility failed to ensure Resident # 93 who required assistance with ADL's did not have long toenails. This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition.

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 3 of 4 medication carts reviewed for medication storage. -The facility failed to ensure LVN F signed off on the Individual Control Record when she administered Morphine on 4/13/26 at 10:00 a.m. This failure could place residents at risk of drug diversion of controlled substances.

Inspectors wroteBased on interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement quality of life for two residents (Resident #1 and Resident #2) of six residents who were reviewed for dignity. The facility failed to report Resident #1's allegation of being double briefed on 03/09/26 to HHSC.The facility failed to report Resident #2's allegation of an unnamed nurse stating she did not speak Spanish to Resident #2 and left without meeting her needs or sending other staff to assist when made aware 02/11/26. This failure could place the residents at risk of poor self-esteem and decrease self-worth.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, were reported to the State Survey Agency, for two Residents (Resident #1 and #2) of six residents reviewed for abuse/neglect. The facility failed to report Resident #1's allegation of being double briefed on 03/09/26 to HHSC.The facility failed to report Resident #2's allegation of an unnamed nurse stating she did not speak Spanish to Resident #2 and left without meeting her needs or sending other staff to assist when made aware 02/11/26. This failure could place the 92 residents who reside in the facility at risk of abuse and neglect.

Inspectors wroteBased on 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 one (Residents #1) of one resident who was provided incontinence care by CNA A observed. CNA A failed to dispose Resident #1's soiled brief after a brief change request and double briefed Resident #1 on 03/07/2026. These failures could affect the residents with incontinence by placing them at risk for the development or worsening of UTIs.

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 to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #3) reviewed for incontinent care in that; -CNA B failed to change her gloves after they became contaminated during incontinent care while assisting Resident #3. The failure could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, that facility failed to extend to the resident representative ' s the right to make decisions on behalf of the resident for 1 of 6 (Resident #1) residents reviewed for resident rights in that: The facility failed to establish who Resident #1 wanted as a responsible party during his stay at the Nursing Facility. This failure could place residents at risk of not having their preferred responsible party represent them in care decisions.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 3 (Resident #41, Resident #60, Resident #250) of 12 residents reviewed for call lights. The facility failed to ensure Resident #41, and Resident #60 had their call lights within reach. The facility failed to ensure Resident #250 had a call light in her room. These failures could place residents at risk for decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice for 2 (Resident #20 and Resident #87) of 12 residents observed for oxygen management. The facility failed to clean the oxygen concentrator air filter for Resident #20 while the oxygen was in use. The facility failed to post an Oxygen sign outside Resident # 87's room who received oxygen. The facility failed to ensure Resident # 87's oxygen tank was properly stored when not in use. This failure could place residents at risk of being exposed to combustion or flammability that may lead to physical harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a safe, clean, comfortable and homelike environment for 1 (room # 104) of 12 rooms reviewed for environment in that: A brown and thick substance was on the floor of room [ROOM NUMBER]' entry way. This failure could have placed residents at risk of residing in an unsafe, unsanitary, and uncomfortable environment.

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 one (Resident #33) of six residents observed for infection control. -Med Aide A failed to don gloves before removing Resident #33's lidocaine 4% patch and before applying new lidocaine 4% patch. Theses failure could place residents at risk for infection and cross contamination.

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 8 residents (Resident #94) reviewed for pharmacy services. Resident #94 had a dixie cup at bed side with Zinc Oxide pomade (skin ointment) and a tongue depressor in it, exposed and within reach of other residents. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observation, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: -4 of 4 oil containers were not labeled or dated. -The seal of the Pork meat stored in the refrigerator was had a ripped hole in foil covering. These deficient practices could place residents who received meals and snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 6 residents reviewed for care plans. -The facility failed to develop a comprehensive person-centered care plan for Resident #1 regarding significant change of condition of a newly diagnosed DVT (a blood clot in a deep vein in the body). -The facility failed to develop a comprehensive person-centered care plan for Resident #1's severe weight loss. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision and that the resident environment remained as free of accident hazards as possible for 2 (100 hall and 200/300 hall shower rooms) out of 3 shower rooms and 1 of 6 residents (Resident #9) reviewed for accidents and supervision. - The facility failed to ensure that razor blades were disposed of properly in the sharp container in two (100 hall and 200/300 hall shower rooms) of three shower rooms. - The facility failed to place fall mat on floor next to Resident #9's bed when she was in bed These failures could place residents at risk for injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #9) of 6 residents reviewed for care plans -The facility failed to follow the comprehensive person-centered care plan for Resident #9's fall risk, by failing to have a fall mat in place next to bed while resident was lying down in bed. This deficient practice could place residents in the facility at risk of of injury.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #1) of 9 residents reviewed for medical records. -The facility failed to ensure the correct method of transfer was documented in the care plan of Resident #1. This failure could lead to errors in treatment and services provided based on incorrect information.

Inspectors wroteBased on interview, and record review the facility failed to ensure the resident environment remained free of accidents hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #2) of 7 residents reviewed for accidents hazards. The facility failed to ensure that Resident #2 who was a two-person transfer was transferred as a two person transfer instead of a one-person transfer. This failure could place residents at risk of falls or injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 2 (Resident #4 and #6) of 8 residents reviewed for reviewed for call light button placement. -The facility failed to ensure that Residents #4's and #6's call lights were within their reach. This failure could place residents at risk of not being able to have their needs met.

Inspectors wroteBased on interview, and record review the facility failed to ensure the resident environment remained free of accidents hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #10) of 6 residents reviewed for accidents hazards. The facility failed to ensure that Resident #10 who was a two-person transfer was transferred as a two person transfer instead of a one-person transfer. This failure could place residents at risk of falls or injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from any physical restraints imposed for purposes of convenience and not required to treat the resident's medical symptoms for three (Residents #84, #71 and Resident #83) of 26 residents reviewed for restraints. 1. The facility failed to ensure a scoop mattress (a mattress with built up sides that create a barrier to help stop residents from rolling or sliding out of bed) was not used with Resident #83 without any medical indication. 2. The facility failed to ensure that bolsters (long thick pillows placed along the sides of the mattress that create a barrier to help stop residents from rolling or sliding out of bed) were not used on the sides of Resident # 84's and #71's beds without the residents having been evaluated for the medical need. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement as well as develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 3 (Resident #84, Resident #40, and Resident #83) of 26 reviewed for care plans in that: The facility failed by implementing a comprehensive person-centered care plan for include a care plan for toenail care for Resident #40 and Resident #83; who were diabetic. The facility failed to include the use of bolsters (long thick pillows placed along the sides of the mattress that create a barrier to help stop residents from rolling or sliding out of bed) in Resident #84's care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 3 of 5 residents (Resident #19, Resident #40, and Resident #83) reviewed for foot care. The facility failed to provide access to a podiatrist for Resident #19, Resident #40, and Resident #83 who were all diabetics. This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition.

Inspectors wroteBased on observation, interview, 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 (dirty utility room) of 1 oxygen crate observed for oxygen management. 1. The facility failed to ensure an oxygen crate with 24 cannisters, in the dirty utility room, was improperly stored. 2. The facility failed to ensure an oxygen sign was posted outside of the dirty utility room where the oxygen tanks were stored. These failures could place residents on oxygen therapy at risk of not receiving oxygen support due to improper storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 (hot water heater for the kitchen) of 1 reviewed for essential equipment. The facility failed to repair or replace the water heater that supplied hot water for washing dishes for the kitchen for 6 days. This failure could place residents who eat in the facility of risk of foodborne illness and decline in health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were free of a med error rate of 5% or greater (12.5%) for 2(Resident #6, 61) of 7 residents reviewed for medication administration. The facility failed to prime insulin pen for Resident #6 before administering Lantus insulin to remove air bubbles from the pen needle to ensure that the needle was open and working. The facility failed to prime insulin pen for Resident #61 before administering Novolog insulin to remove air bubbles from the pen needle to ensure that the needle was open and working. The failures placed residents at risk of incorrect doses of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. -1 bag of thin fillet steaks found in freezer removed from the original package without a label of its contents. -1 bag of frozen French fries found in freezer removed from the original package without label of its contents and opened to air, stored in box on top of frozen corn. -Approximately 40 half ham and cheese sandwiches found in walk-in refrigerator on two trays not labeled or dated. -Aluminum foiled pieces of bacon found in walk-in refrigerator partially open to air and not labeled or dated. These failures could place residents at risk of food-borne illness.

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 1 (Resident #6) of 7 residents reviewed for assistance with ADLs -The facility failed to ensure Resident #6, who required assistance with ADLs, did not have long fingernails. This failure could affect residents who were dependent on assistance with ADLs and could result in poor care, lack of dignity, and skin tears due to long nails.

Inspectors wroteBased on interview, and record review the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 7 (Resident #1) residents reviewed for accuracy of records. -The facility failed to accurately document Resident #1's weight in her weight record on 11/21/2023. This failure could place residents at risk of having incomplete and inaccurate records with the risk of not receiving potential needed services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a written notice of room change was received, including the reason the room was changed, for 4 of 4 residents (Residents #1, #6, #7, and #8) reviewed for notification of room change. -The facility failed to provide Resident #1, Resident #6, Resident #7, and Resident #8 a written notice of a room change before the resident was moved. This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment. Findings Included: Resident #1: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs and described the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 5 residents reviewed for care plans -The facility failed to follow the comprehensive person-centered care plan for ADL self-care performance deficit requiring two-person participation for toileting and transfers. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained free of accidents hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 2 (Resident #1 and #4) of 6 residents reviewed for accidents hazards. The facility failed to ensure wheelchair brakes were secured during mechanical lift transfers of Resident's #1 and #4. These failures could place residents at risk of injuries.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, and administering of medications for 1 (Resident #1) of 4 residents reviewed for pharmacy services, in that: Resident #1's medication, Levothyroxine Sodium Oral Tablet 175 mcg, to be administered one time a day for hypothyroidism, was not available at the facility for scheduled administration as ordered by the resident's physician for two days. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and could result in worsening of medical condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for 1 (11/13/2023) of 3 days reviewed for nurse staffing information. The facility failed to post the required staffing information for 11/13/2023. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.