St. Teresa Nursing & Rehab Center

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 four of four community shower rooms, and for one (Resident #2) of four Resident Rooms reviewed for infection control. -The facility failed to ensure clean linen carts were not stored in the community shower rooms where they stored the dirty linen hampers that were full of soiled linen and were not completely sealed. -The facility failed to ensure nursing staff were not storing Resident #2's soiled clothing on the floor in the resident's closet. These failures could result in increased risk of infection to residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 4 of 12 water heaters. The facility failed to maintain 4 of 12 water heaters that provided hot water to 4 of 4 resident units resulting in the water heaters being not operational for over a month. This failure could place the residents at risk of an unsafe environment by not maintaining mechanical equipment in safe operational condition.

Inspectors wroteBased on observations and interviews 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 of his or her quality of life, recognizing each resident's individuality for 1 (Resident #2) of 5 Resident reviewed for Resident Rights. The facility failed to ensure Resident #2's dignity was maintained when he was left in urine-soaked clothing, his bedding was urine soaked, and his room had a strong urine smell. This failure put residents at risk of not being treated with dignity and respect and not being care for in an environment the maintains the resident's quality of life.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances, for 1 (Resident #5) of 5 residents reviewed for grievance resolution. The facility failed to ensure that the grievance filed by Resident #5 on 05/27/26 was resolved when she had complained that the CNAs were showering other residents in her room without her permission. These failures could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming and personal hygiene for 1 (Resident #2) of 5 residents reviewed for quality care.-The facility failed to provide incontinent care to Resident #2 according to the comprehensive person-centered care plan. This failure could place residents at risk of not receiving the necessary personal care to maintain the resident's dignity and prevent skin irritation and skin breakdown.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 2 (Resident #1 and Resident #2) of 11 residents observed for oxygen management. The facility failed on 06/05/2026 to ensure oxygen warning signs were posted outside the rooms of Resident #1 and Resident #2 while the residents were receiving oxygen therapy. The facility failed on 06/05/2026 to ensure oxygen cylinders not actively in use were stored in the designated oxygen storage room and instead left them inside Resident's #1 and Resident #2's room. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment are thoroughly investigated to prevent further potential while the investigation is in progress for 1 of 9 residents (Residents #3) reviewed for misappropriation. The facility failed to ensure the Administrator followed the facility's policy, by not completing an investigation, and reporting an allegation of misappropriation involving Resident #3. These failures could place residents at risk of not being provided services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that the residents environment remains as free of accidents hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #1) of 24 residents observed. The facility failed to dispose of an empty syringe and left it on top of Resident #1's dresser located in the room. This failure could place residents at risk of accidents, and potential harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 of 24 residents (Resident #2) reviewed for infection control in that:PPE (Protective equipment such as gowns and gloves) was not used properly by LVN H when performing an IV insertion and properly handling sharps for Resident #2. The deficient practice could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 2 of 2 residents (Residents #1 and #2) reviewed for records. The facility failed to provide an accurate report to HHSC on self-reportable incidents. This deficient practice could place residents at risk of not having accurate documentation and put residents at risk for further incidents of abuse or neglect.

Inspectors wroteBased on 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, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Residents #1) reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident #1 to address the fall that occurred in the facility on 12/25/25. This failure could place residents at risk for not receiving care and services to meet their needs. Findings Include:Record review of Resident #1's face-sheet, dated 02/03/2026, revealed an [AGE] year-old female with initial admission date of 11/14/25 and re-admission date 12/20/25. [...]

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 1 of 4 residents (Resident #2) reviewed for transmission-based precautions. The facility failed to ensure the Wound Care RN provided wound care per facility policy on 02/04/26. This deficient practice could place residents at risk of exposing them to care that could lead to the spread of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent with bowel and bladder received appropriate treatment and services to prevent urinary tract infections for 2 (Resident #1 and Resident #2) of 4 residents reviewed for incontinence care. - The facility failed to ensure Resident #1's and Resident #2's foley catheter drainage tubes were secured with Catheter Holder prior to turning & repositioning the residents in bed. - The facility failed to ensure CNA B provided perineal care according to facility policy and procedure for Resident #1 when she failed to clean the perineal area from front to back when providing perineal care on 12/18/25. These failures placed residents at risk for the development and/or worsening of urinary tract infections and dislodgement of the foley catheter.

Inspectors wroteBased on interview and record review, the facility failed to ensure the discharge needs of each resident are identified and the discharge planning process results in the development of a discharge plan for each resident for 1 (Resident #1) of 4 residents reviewed for discharge planning. The facility failed to develop a discharge plan when Resident #1 was issued a 30-Day Discharge Notice on 11/26/25 due to non-payment. This failure could result in residents experiencing psychosocial harm due to inappropriate discharges and placed residents at risk of being discharged without alternate placement and not having access to available advocacy services, discharge/transfer options, and denying them their rights in the appeal process.

Inspectors wroteBased on interviews and record review the facility failed to ensure a facility with more than 120 beds employed a qualified social worker on a full-time basis. The facility failed to have a full-time social worker since 12/11/25, to address Grievances and complete Discharge Plans. This failure put facility residents at risk of not having their psychosocial or discharge planning needs met.

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 1 of 4 residents (Resident #3) reviewed for Enhanced Barrier Precautions. The facility failed to implement their policy on Enhanced Barrier Precautions during high contact resident care activities for Resident #3 who had a wound and indwelling medical device. This failure could place residents at risk for healthcare associated cross-contamination and at risk of the transmission of multi-drug-resistant organisms (MDROs).

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 3 of 12 residents (Residents #84, Resident #88 and #67) reviewed for call lights. This failure placed residents at risk of having their needs unmet when they are unable to contact staff.

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.-The facility failed to maintain a one-gallon bottle of sweet and sour sauce free from dried drippings in the pantry on 09/14/2025.-The facility failed to maintain a one-gallon bottle of mustard free from dried drippings inside of the walk-in refrigerator on 09/14/2025. These failures could place all residents who received meals from the main kitchen at risk of food borne illnesses.

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 two residents (Residents #1, and #4) of twelve residents reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident # 1 to address resident's Tracheostomy care. The facility failed to have a comprehensive person-centered care plan for Resident #4 to address resident's psychotropic medication prescriptions, Trazadone and Buspirone. These failures could affect residents and put them at risk for not receiving care and services to meet their needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ADL care for 1 of 16 residents (Resident # 99) reviewed for ADLs. The facility failed to ensure Resident #108's nails were clean and trimmed. This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem. Record review of Resident #108's face sheet dated 09/16/25 revealed a [AGE] year-old female with an admission date 05/06/25 and re-admission date 09/09/25. Record review of Resident #108's quarterly MDS dated [DATE] revealed BIMS was not completed since resident was rarely or never understood. Quarterly MDS revealed Resident #108 was Dependent for personal hygiene, meaning the helper does all the effort while the resident does none of the effort to complete the activity. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as was possible for 2 of 5 residents (Resident # 110 and # 113) reviewed for accidents. The facility failed to properly recover and dispose of a shaving razor left inside the shared bathroom for Resident # 110 and # 113. The deficient practice could place residents at risk of harm and injury and contribute to avoidable accidents.

Inspectors wroteBased on 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 and failed to ensure drug records were in order and that an account of all controlled drugs was maintained for 1 (Resident#33 ) of 6 reviewed for medication administration. The facility failed to ensure Licensed Staff Registered Nurse E signed the individual control drug record for Resident #33's after administering controlled medication on 09/16/2025. This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to be free from abuse was provided for 2 (Resident #1 and Resident #2) of 8 residents reviewed for abuse, in that: The facility failed to protect Resident #1 from abuse on 3/20/25 when Resident #1 hit Resident #2 on the face. As a result, there was bruising immediately starting to form on Resident #1's right side of face close to the right [NAME], bruising notes to right hand on knuckles, and bruise noted to right shin. The noncompliance was identified as past noncompliance (PNC). The noncompliance began on 03/20/2025 and ended on 03/25/2025. The facility had corrected the noncompliance before the investigation began. These failures could place residents at risk of abuse, injury, intimidation, fear, agitation, and psychological harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 (Resident #1) of 6 residents reviewed for gastrostomy tube management quality of care. -The facility failed to ensure Residents #1 was provided with the correct feeding through gastrostomy tube (g-tube, feeding tube) as ordered. This failure could place residents who received feedings by gastrostomy tube at risk for weight gain and decline in health.

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 complete and accurately documented for 1 of 4 residents (Resident #3) reviewed for medical records. The facility failed to ensure Resident #3's inventory record accurately documented items for the resident during her stay at the facility. This failure could place residents at risk of lost, missing or stolen items.

Inspectors wroteBased on 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 #3) of 8 residents reviewed for care plans. -The facility failed to develop and implement a comprehensive person-centered care plan for Resident #3's use of a BiPAP machine. 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 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 2 (Residents #16, and #17) of 8 residents reviewed for assistance with ADLs. -The facility failed to ensure Residents #16 and #17, who required assistance with ADLs, did not have long and dirty fingernails. These failures could affect residents who were dependent on assistance with ADLs and could result in poor care, lack of dignity, infection, and skin tears due to long nails.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #11) of 11 residents reviewed for quality of care. The facility failed to ensure that Resident #11's enteral feeding formula was properly labeled. This failure put residents at risk of not receiving adequate nutrition by way of enteral feeding.

Inspectors wroteResident #97 Advance Directives 07/23/24 12:27 PM DNR per electronic record - no DNR document scanned into miscellaneous documents. 07/25/24 02:44 PM Socual worker [NAME] - adult Som requested DNR. Did requrest for DIN and in itniated DNR request - CUfrrent status is pendin MD signature on the DNR docuemtn. Her compliance nrusing team that if they makde a rfeuest in house to honor the client's desired so - have to get TX OOH DNR - Valid DNR for in house. No completed hospital DNR. It is a catch 22. 07/25/24 03:51 PM DON - if a resident requests refer to SW Resident #259 Advance Directives 07/24/24 08:44 AM Appears that OOH DNR is not signed by MD. Social worker [NAME] - this is not a valid completed - The facity strated the enactment process, DNR and was scanned in . She did revie with [NAME]. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure that residents were not given psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for three (Residents #27, #93, and #255) of 5 residents reviewed for unnecessary medications. The facility failed to ensure Resident #27 did not receive Risperidone, an anti-psychotic to treat Delusional disorder. The facility failed to ensure Resident #93 did not receive Aripiprazole, an antipsychotic to treat depression. The facility failed to ensure Resident #255 did not receive Quetiapine, an antipsychotic to treat dementia. These failures could place residents at risk for adverse consequences such as impairment or decline in an individual's mental, physical or psychosocial status from receiving unnecessary antipsychotic medications.

Inspectors wroteResident #4 Urinary Catheter or UTI Resident #23 Urinary Catheter or UTI Resident #33 Urinary Catheter or UTI Based 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 4 of 5 residents (Residents #4, #33, #73, and #155) reviewed for infection control. The facility failed to ensure airborne precautions were followed for Resident #155 who had Shingles. The facility instructed staff to follow contact precautions. The facility failed to ensure Residents #4, #33, and #73's urinary catheters were not on floor. This failure could affect residents by placing them at an increased risk of exposure to communicable diseases and infections.

Inspectors wroteFACILITY Environment 07/25/24 03:40 PM DON regarding oxygen filters - get Rt arersponsible o makding [NAME] ethat oxyven macings are functionion gprooperlly. should be checking the filters. Risk to residednt not ereceiving desired effect of the oxygen. Not Getting enough oxygen, increase risk of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents were free from physical restraints that were not required to treat the resident's medical symptoms for 1 (Resident 259) of two residents reviewed for physical restraints. The facility failed to assess whether Resident #259's concave mattress was a restraint before placing it on her bed. This failure put residents at risk of the use of equipment that might restrict their movement.

Inspectors wroteResident #93 Dementia Care 07/24/24 04:44 PM LOS - 6/25/2024 7/23/2024 Care plan for dementia not in place. BIMS of 13 on 5-day MDS Diagnosis - Receiving Apriprazole for depression MDS 5 day Jun 28, 2024 shows DX - non-Alzheimer's dementia, Depression - no other psych/mood disorder shown. Care Plan - requires antipsychotic - monitor for side effects. Resident #97 Position, Mobility 07/23/24 09:32 AM Resident states they are not doing anything to address her range of motion of arms or legs. MDS Jun 11, 2024 - 5-day - Dependent for Toileting, dressing, Showering did not occur Substantial/maximal assistance - Roll right and Left, sit to lie, sit to stand, transfers. OT - 95 minutes over three days stating 6/7/24 PT - 98 mins over three days starting 6/7/24 No time recorded for Restorative. Order: PT eval completed this date. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #97) of 17 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure that Resident #97's comprehensive care plan included interventions to address urinary tract infection, shortness of breath, hypotension (low blood pressure), impaired cognitive function, cellulitis (skin infection), potential nutritional problem, mood problem, and depression. The facility failed to ensure that Resident #97's comprehensive care plan for a self-care deficit specified which areas of function were to be maintained or improved (such as bed mobility, transfers, or toilet use). [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide necessary services to maintain good grooming and hygiene for a resident who was unable to carry out activities of daily living for 2 (Residents #26 and #29) of 12 residents reviewed for services to maintain good grooming and hygiene. The facility failed to provide personal hygiene for Resident #26 and #29 by not trimming their fingernails. This deficient practice placed residents at risk of poor hygiene and decline in residents' self-esteem.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for one (Resident #97) of 3 residents reviewed for treatment and services to increase range of motion and/or to prevent further decrease in range of motion. The facility failed to provide Resident #97 with treatment and services to address her limited range of motion. This failure could put Resident #97 at increased risk of contractures and impaired skin integrity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident reviewed for accident hazards/supervision. (Resident #23). The facility failed to ensure HA H and NA I demonstrated appropriate transfer techniques while using the mechanical lift for Resident #23. These failures could place residents at risk for injuries.

Inspectors wroteResident #97 Urinary Catheter or UTI 07/23/24 09:36 AM cath bag in privacy bag resting on fall mat 07/23/24 09:33 AM Interview observation with [NAME] - Cath bag on floor - photo taken. 07/23/24 09:58 AM [NAME], LVN - adjust bed so bag is not on fall mat. States bag is touching because of fall mat, should not be on the floor for infection control reasons. 07/25/24 03:22 PM DON - regarding cath bag o nthe floorit doses have a privacy bag. Doe nto know policy as to wehtehr the bag is sufficient protection. IF the bag is not sufficient protection there is a risk for intection - CNAs asll clinical staff responsible fo thei .

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 two (Residents #256 and #38) of 7 residents reviewed for provision of respiratory care. The facility failed to ensure that Resident #256's oxygen concentrator filter was free of accumulations of dust. The facility failed to ensure that Resident #38's oxygen concentrator filter was free of accumulations of dust. This failure put residents at increased risk of inhaling dust and germs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 (Residents #210) of 12 residents and for 2 of 5 medication carts reviewed for pharmaceutical services. LVN A did not administer Resident #210's scheduled multivitamin with minerals as indicated by the physician orders. The medication cart used for hall 400 and 500 had insulin pens that had expired as indicated by the manufacturer's instructions. These failures could place residents at risk of not receiving medications as prescribed or the therapeutic benefit of medications or at risk of receiving medications that were expired and not produce the desired effect and under dosed.

Inspectors wroteFACILITY Medication Administration During an interview and observation on [DATE] at 01:14 PM LVN [NAME] said she had given Resident #210 [NAME] the multi vitamin in the bottle which had the blue label that indicated High potency multivitamin supplement further inspection of the bottle revealed that it did not contain minerals as indicated on the supplement facts label. LVN [NAME] said she was aware of the resident ordered to have a multi-vitamin but was not sure if they had any of the one with minerals. LVN [NAME] then went to the medication room to look for vitamin with minerals and in the medication room was found some vitamin with minerals which she then took the place in the medication cart. LVN [NAME] said that earlier there were no vitamin with minerals bottles in the medication room. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed maintain medical records on each resident that were accurately documented for 3 of 12 residents reviewed for medical record accuracy. (Resident #97, #155 and #259) - The facility failed to ensure that Resident #97's a Texas Out of Hospital DNR was completed prior to documenting in the resident's chart that she had a DNR status - The facility failed to ensure Resident #155 who was listed as DNR (Do Not Resuscitate) had an Out-of-Hospital Do Not Resuscitate (OOH-DNR) form. - The facility failed to ensure that Resident #259's Texas Out of Hospital DNR had been signed by a physician prior to documenting in the resident's chart that she had a DNR status This deficient practice could place residents at risk of having their end of life wishes dishonored, and of having cardiopulmonary resuscitation (CPR) performed against their wishes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the prompt resolution of all grievances to include ensuring that all written grievances decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent finding or conclusions regarding the resident's concerns; a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 1 of 10 (resident #22) reviewed for resident rights. The facility failed to initiate and complete a grievance for Resident #22's family who voiced concern of unidentified CNAs not closing the curtain when providing perineal care. [...]

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 2 (Residents #19 and #20) of 7 residents reviewed for assistance with ADLs. -The facility failed to ensure Residents #19 and #20, who required assistance with ADLs, did not have long fingernails. These failures 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 observation, interview, and record review, the facility failed to provide reasonable accommodations of needs for 1 (Resident #19) of 15 residents reviewed for call light button placement. -The facility failed to ensure that Residents #19 call light was within his reach. These failures could place residents at risk of not being able to have their needs met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure to ensure personal privacy during personal care for 1 of 10 (resident #22) whose care was reviewed in that: The facility failed to close the curtain when providing perineal care to Resident #22. This deficient practice could place residents at risk of dignity, low self-esteem and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident recieves adequate supervision and assistance devices to prevent accidents for 1 (Resident #21) of 9 residents reviewed for care ADLs. -The facility failed to follow the comprehensive person-centered care plan for ADL self-care performance deficit requiring two-person participation for bathing. 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, accidents and potential harm.

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 of 10 (resident #22) reviewed for oxygen therapy. The facility failed to replace Resident #22 tracheostomy ventilation circuit tubing that was seen with red/brownish particles for 2 days. This failure could place residents on oxygen therapy at risk of cross contamination resulting in acquired infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #10) of 10 residents reviewed for assistance with ADL's. CNA G failed to ask for assistance on 3/7/24 when providing perineal care to Resident #10, who required 2-person assistance, that resulted in fall with injury. This failure resulted in actual harm to Resident #10 on 03/07/24. It was determined to be past non-compliance due to the facility having implemented action that corrected it before the investigation began. This failure could place residents at risk of accidents and potential harm.

Inspectors wroteBased on observation, interview, record review the facility failed to ensure that a resident who is continent of bladder and bowel on admission receives services and assistance to maintain continence unless his or her clinical condition is or becomes such that continence is not possible to maintain for 2 of 5 (Resident #9 and Resident #4) residents reviewed for urinary catheter. The facility failed to ensure Resident #9's urinary foley bag was placed below the bladder. The facility failed to provide catheter care for Resident #4 every shift. This failure could place residents with urinary catheters at risk of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable disease and infection for 1 (Resident #9) of 2 residents reviewed for perineal care and 1 (Resident #7) of 3 residents reviewed for infection control in that: Resident #7 was Covid-19 positive in January 2024, and the facility failed to record in the Infection Control Log for its Surveillance (a tool used to analysis data that can uncover an outbreak). CNA B failed to change gloves after cleaning Resident #9's BM and continued to provide ADL assistance with dirty gloves. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records on each resident were complete and accurately documentd for 1 (Residents #7) of 2 residents reviewed for physician orders in that: There were no physician orders for Resident #7 who was Covid-19 positive on 01/31/24 and placed in isolation. This deficient practice could place Covid-19 positive residents at risk of decline in psychological mental health.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #1, Resident #2, and Resident #3) of 5 residents reviewed for call light button placement. The facility failed to ensure that Residents #1, #2, and #3 call lights were within their reach. This failure put residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to have a safe, clean , comfortable and homelike environment including but not limited to receiving treatmentand supports for daily livining safely for 1 (hall 300) of 4 hallways and 1 ( Residents #1's bathroom ) of 5 bathrooms reviewed for infection control in that: 1. PPE (Protective equipment such as gowns and gloves) were not disposed of properly in hallway 300. 2. Trash with briefs and bowel movement were not properly disposed and remained in a resident's bathroom. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review the facility failed to develop and implemment written policies and prodcueres that: Each covered individual shall report to the State Agency and one or more law enformecent entities for teh poltiical sibdivudsion in which the facility was located any reasonable suspicion of a crime against any indeividual who was a resident of or was receiving care from teh facility for 1 (Resident #4) of 5 residents reviewed for allegations of abuse. The DON and Administrator failed to immediately report to the state survey agency when Resident #4 claimed she was physically hit on her left arm and her left wrist by a nurse. This failure could place all residents at risk for abuse by not immediately reporting allegations of abuse to the proper authorities.

Inspectors wroteBased on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that included measurable objectives and time frames to meet a residents medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 5 residents (Resident #6) reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #6's showering in a shower bed . This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for 1 of 6 residents (Resident #5) reviewed for accuracy of records. The facility failed to complete a baseline care plan for Resident #5's new seizure diagnosis. This failure could place residents at risk of not having accurate and complete information available to those providing their treatment and care.

Inspectors wroteBased on 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 6 residents (Residents #1) reviewed for medication administration. The facility failed to ensure LVN A did not borrow Buspirone HCL from another resident to administer to Resident # 1 . This deficient practice could place residents at risk of not being administered medications according to physician's orders .

Inspectors wroteBased on interview, and record review the facility failed to take reasonable steps to make residents and family members aware of upcoming meetings in a timely manner for four of four (January, February, March, and April 2023) resident group meetings reviewed for steps to make residents and family members aware upcoming meetings., The facility changed the date and/or the time of group meetings in January, February, March, and April 2023 on 4 occasions after posting the meetings on activity calendars distributed throughout the facility. This failure put residents and family members at risk of decreased opportunities to present grievances and recommendations.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 (Resident #86, Resident #76, Resident #99) of 10 residents observed for assistance with ADL's. The facility failed to ensure facility staff provided nail care for 3 residents (Resident #86, Resident #76, and Resident #99). This deficient practice could place residents who were dependent on assistance with ADLs at risk of not receiving assistance with personal care which could result in poor care, skin breakdown, and feelings of poor self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received care, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for three (Residents #48, #56, and #83) of five residents reviewed for pressure ulcer prevention and treatment. The facility failed to prevent the further development of a Stage 4 pressure sore for Resident #48 by failing to change the dressing as needed when soiled. The facility failed to change Resident #56's Stage 4 wound care dressing according to physician's orders. Resident #83 did not receive four treatments for Stage 4 pressure ulcers that were ordered by her physician. These failures could place residents at risk for developing new or worsening of existing pressure injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident was provided foot care and treatment, or provided assistance in making appointments for treatment for 1 Resident #74) of 10 residents observed for assistance with ADL's. Resident #74 wanted his toenails cut but had not received podiatry services. This deficient practice could place residents who were dependent on assistance with ADLs at risk of not receiving assistance with personal care which could result in poor care, skin breakdown, and feelings of poor self-esteem.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents received parenteral fluids consistent with professional standards of practice and in accordance with physician orders for 2 (Resident #78 and Resident #56) of 2 residents reviewed for Midline (midline catheter inserted in the upper arm)/PICC (Peripherally Inserted Central Catheter) care. The facility failed to change Resident #56's and Resident #78's Midline line dressing according to physician's orders. This deficient practice could have placed residents at risk for cross-contamination resulting in acquiring infections.

Inspectors wroteBased on interview and record review the facility failed to ensure that there were sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident including licensed nurses and nurse aides for 5 of 11 residents who attended a confidential group meeting. Staff shortages on the weekends resulted in missed showers, missed, or delayed response to call lights, delayed medication administration, and delayed meals. These failures put residents at risk of decreased physical, mental, and psychosocial well-being.

Inspectors wroteBased on the observations, interviews, 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 residents. 1. Foods in the dry storage, walk in refrigerator, and freezer were not dated or labeled properly. 2. Food containers and food bags were not properly sealed in the kitchen and in the Refrigerator. This failure could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents had the right to be free from any physical restraints not required to treat the resident's medical symptoms for one (Resident #98) of three residents reviewed for physical restraints. Resident #98 was placed in a Geri-chair (a specialized reclining chair ), the need for which he had not been evaluated, for which there was no doctor's order and for which representative consent was not obtained. This failure put residents at risk of being restrained without justification of the need for a restraint.

Inspectors wroteBased on interview and record review, the facility failed to report immediately an alleged violation involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property to other officials including State survey and certification Agency in accordance with state law for 1 of 7 (Resident #203) reviewed for abuse. The Administrator failed to report to an injury of unknown origin that was reported to him on 04/19/23 by the local ombudsman to the State Agency with in the required time frames. The LVN Q failed to report bruising of unknown origin to the DON and or the Administrator immediately after assessing the resident. This deficient practice could place residents at risk for further endangerment if allegations of abuse, neglect, misappropriation and injuries of unknown origin are not thoroughly investigated. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that resident received appropriate treatment and services to prevent physical trauma when providing care by failing to ensure the resident urinary catheter and tubing were secured in 1 (Resident #78) out of 4 residents reviewed for indwelling catheter. The facility failed to provide appropriate treatment to prevent physical trauma by not securing the urinary catheter and tubing. This deficient practice placed residents with an indwelling catheter at risk of obtaining physical trauma when receiving improper care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an acceptable parameter of nutritional status was maintained for 2 residents (Resident #76 and Resident #10) of 10 residents reviewed for weight loss. The facility failed to monitor, document residents' weight's, care plan, and place interventions to prevent further weight loss for Resident # 76 and Resident #10 for significant weight loss. This failure could place residents in the facility at risk for compromised nutritional status, weight loss, and not being able to maintain their highest practicable level of health.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure a resident who is fed by enteral means receives appropriate treatment and services to prevent complicantions for 1 (Resident #86) of 6 residents reviewed and 1 out 5 drugs/biologicals reviewed for labeling in that: The facility failed to ensure Resident # 86's enteral feeding bag was labeled with the resident's name, date, time feeding was hung, the rated order to infuse. This deficient practice could place resident who receive enteral feeding at risk of decline in health due to labeling errors.

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 (Resident #30) of 10 residents observed for oxygen management. 1. Resident #30 was not receiving weekly changes of oxygen tubing and nasal cannula/mask according to physician's orders. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health.

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 (Residents #2) of 4 reviewed for medication administration. The facility failed to ensure that RN L administered Resident # 2's medications according to the scheduled medication time. This deficient practice could place residents on the 400 on the hall in the even shift at risk of not receiving their medication in accordance with the scheduled time.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident's drug regimen was free from psychotropic drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for one (Resident #98) of 5 residents reviewed for unnecessary medications. Resident #98 was prescribed an antipsychotic medication (Quetiapine Fumarate) for treatment of dementia with major depressive disorder. This failure puts residents at risk of medication side effects as a result of being administered unnecessary antipsychotic medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure it was adequately equipped to allow residents to call for staff assistance through a communication system which relayed the call directly to a staff member or to a centralized staff work area for 1 (Resident #45) of 4 resident rooms reviewed for resident call systems. The facility failed to ensure 1 Resident #45 room had a workable outside door light. This failure could place residents at risk of being unable to obtain timely assistance for activities of daily living or in the event of an emergency.