Sulphur Springs Health and Rehabilitation

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to exercise their rights and to be treated with respect and dignity for 1 of 2 residents (Resident #1) reviewed for resident rights. The facility failed to honor the request by Resident #1's to change his Medical Power of Attorney on 06/04/26 after his care plan meeting. This failure could place residents at risk of not having their preferred responsible party represent them in medical or care decisions.

Inspectors wroteBased on interviews and record reviews, it was determined that the facility failed to ensure residents have the right to receive visitors of his or her choice and at the time of his or her choosing for 1 (Resident #2) of 10 Residents reviewed for resident rights. The facility did not allow Resident #2 to visit or talk with her Family Members E and G when they called and or came to the facility when Resident #2 wanted to have visitors and calls. This failure could place residents at risk of isolation, decreased emotional wellbeing, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 8 of 8 confidential residents, and 1 of 1 meal reviewed for palatability, attractiveness, and appetizing foods. The dietary staff failed to provide food that was palatable and at an appetizing temperature for residents. This failure could place residents at risk of a decreased food intake, hunger, and unwanted weight loss.

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 the facility's 1 of 1 kitchen reviewed for food safety requirements. The facility failed to ensure there was not dust on the air vent above the preparation area. The facility failed to ensure there was no dust and bugs inside the light fixture above the stove. The facility failed to ensure floors did not have a sticky substance. The facility failed to ensure the skillet did not have a carbon buildup around the edge. The facility failed to ensure the baking sheet did not have a carbon buildup around the edge. The facility failed to ensure there was no trash laying on the ground, spilled out of trash bag, in the outdoor garbage dumpster. [...]

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 facility reviewed for pest control. The facility failed have an effective pest control program to eradicate the cockroaches in the facility. This facility failure could place residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 of 24 residents (Resident #15, Resident #10, and Resident #4) reviewed for care plans. The facility failed to ensure Resident #15's care plan included her medication Eliquis (an anticoagulant) and interventions. The facility failed to ensure Resident #4's care plan included her medication Eliquis (an anticoagulant) and interventions. The facility failed to follow Resident #10's care plan for palm protectors. These failures could place residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 3 of 5 residents (Resident #45, Resident #37, Resident #19) reviewed for pressure ulcers. The facility failed to change Resident #45, Resident #37, Resident #19's wound dressings according to the physician's orders. This failure could place residents at risk of not receiving wound care services appropriately, could contribute to a decline in a wound, infection and a decline in physical, mental and psychosocial well-being.

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 2 of 7 residents (Residents #20, and #5) and 2 of 2 staff reviewed for infection control.1. The facility failed to ensure CNA B thoroughly cleaned the peri area, changed gloves, and used hand hygiene before going from dirty to clean while providing incontinent care to Resident #20. 2. The facility did not ensure EBP were put in place for Resident #5. 3. CNA Q failed to perform hand hygiene between resident to resident contact when passing meal trays. 4. CNA R failed to perform hand hygiene between resident to resident contact when passing meal trays. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers,. for 1 of 6 (Resident #1) residents reviewed for psychoactive medications. The facility did not ensure written consent was obtained from the legal authorized representative on HHSC Form 3713 to administer Abilify 10 mg also known as Aripiprazole (atypical antipsychotic medication used to treat schizophrenia, bipolar I disorder, depression, autism-related irritability, and Tourette's syndrome) for Resident #1. This failure could place residents at risk for receiving unnecessary antipsychotic medications without informed consent.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, 1 of 24 (Resident #11) reviewed for abuse. The facility did not implement their policy on reporting abuse to the Abuse Coordinator when Resident #11 stated the word rape while been provided a shower by CNA L. This deficient practice could place residents at risk of unreported abuse, neglect, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, to the administrator of the facility and to other officials including to the State Survey Agency for 1 of 24 (Resident #11) residents reviewed for abuse and neglect. The Abuse Coordinator failed to identify and report an allegation of abuse to HHSC within 2 hours when LVN H informed him on 03/23/26 that Resident #11 stated the word rape and appeared scared while been provided a shower by CNA L. This failure to report could place the residents at risk for abuse and emotional distress.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure the services provided, as outlined by the comprehensive care plan, met professional standards of quality, for 1 of 2 residents (Resident #13) reviewed for services provided to meet professional standards. The facility did not ensure Resident #13's hospice POC reflected her medication regimen. This deficient practice could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident 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 grooming, and personal and oral hygiene were provided for 1 of 6 residents (Resident #10) reviewed for ADL care. The facility failed to ensure Resident #10's fingernails were free from a brown material substance. This failure could place residents at risk of not receiving care/services, and decreased quality of life impacting their loss of dignity.

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, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 residents (Resident #43) reviewed for quality of care. The facility did not ensure that LVN A followed physician orders for wound care on Resident #43's right second toe on 03/21/26 and 03/22/26. This failure could place residents at risk for a decline in wounds, infection, pain and a decline in functional abilities.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible for 1 of 24 residents (Resident #51) reviewed for accidents and hazards. The facility failed to ensure CNA N locked the mechanical lift when transferring Resident #51 from his wheelchair to his bed. These failures could place residents at risk of accidents that could result in serious injury, harm, impairment, or death.

Inspectors wroteBased on observation, interview, and record review the facility failed provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 2 of 7 resident (Residents #5 and #15) reviewed for pharmacy services. 1. The facility did not ensure LVN A administered Resident #5's Sevelamer Carbonate (a medication used to manage high blood phosphorus levels in adults with chronic kidney disease) 800 mg on [DATE]. 2. The facility failed to ensure Resident #15's Novolog insulin vial (medication used to administer to residents with high blood sugars) on the west nurse medication cart was not expired prior to placing the open date of [DATE] on the bottle. These failures could place residents at risk for weak bones, joint pain, severe itching, and fractures.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 2 of 6 residents (Resident #15 and Resident #4) reviewed for pharmacy services. 1. The facility failed to monitor Resident #15 for side effects/adverse reactions for the use of Eliquis (an anticoagulant medication- blood thinner). 2. The facility failed to monitor Resident #4 for side effects/adverse reactions for the use of Eliquis (an anticoagulant medication- blood thinner). These failures could place residents at risk of swelling, bruising, and bleeding.

Inspectors wroteBased on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of its residents for 2 of 24 residents (Resident #6 and Resident #5) reviewed for laboratory services. 1. The facility failed to obtain Resident #6's CMP (lab test that provides an overall picture of your body's chemical balance and metabolism, and can help diagnose, screen for, or monitor health conditions or medication side effects), CBC (used to monitor and diagnose medical conditions, check the health of the immune system, and detect disorders including infections, anemia, and blood cancer), and HgA1c (lab test that provides a measurement of the average of the blood sugars in the last 2-3 months to manage diabetes) as ordered on 11/18/25 and every 3 months.2. [...]

Inspectors wroteBased on 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 dietary services. 1) The facility failed to dispose of expired food items in the refrigerator and freezer. 2) The facility failed to clean deep fryer weekly. 3) The Facility failed to label and date all food items in the refrigerator and freezer. These failures could place residents at risk for food contamination and foodborne illness.

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 failed to ensure each resident received supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #14) reviewed for accidents and supervision. 1. The facility failed to ensure 2-person assistance was used while providing Resident #14 a bed bath on 06/09/2024. This resulted in Resident #14 falling out of bed and fracturing her right distal tibia (right lower end of the leg). 2. The facility failed to ensure staff knew where to find resident information on the required level of assistance each resident needed. An Immediate Jeopardy (IJ) situation was identified on 12/11/2024 at 4:25 PM. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities both facility sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interation in the community for 3 of 3 residents (Residents #13, #42 and #48) reviewed for activities. The facility failed to provide their scheduled activities on December 9th, 10th and 11th for all residents which included Residents #12, #42 and #48. This failure could place residents at risk for not having activities to meet their interests or needs and a decline in their physical, mental, and psychosocial well-being.

Inspectors wroteBased on 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 dietary services. 1) The facility failed to date all food items. 2) The dietary staff failed to properly seal refrigerated food items. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observations, interviews, 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 2 of 4 residents (Residents #47 and Resident #3) reviewed for infection control practices. 1. The facility failed to ensure CNA Q used proper hand hygiene between glove changes while she provided incontinent care for Resident #47. 2. The facility failed to ensure CNA P and LVN R complied with Enhanced Barrier Precautions when providing incontinence care for Resident #3 These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the promote resident had the right and the facility promoted and facilitated resident self-determination through support of resident choice for 1 of 6 residents (Resident #51) reviewed for resident rights . The facility failed to ensure Resident #51 was assisted out of bed per his preference on 12/09/2024 . This failure could place dependent residents at risk for feelings of depression, lack self-determination, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide the resident access personal and medical records pertaining to him or herself, upon an oral or written request, in the form and format requested by the individual, if it is readily producible in such form and format (including in an electronic form or format when such records are maintained electronically, or, if not, in a readable hard copy from such other form and format as agreed to by the facility and the individual, within 24 hours (excluding weekends and holidays) and allow the resident to obtain a copy of the records or any portions thereof upon request and 2 working days advance notice to the facility for 1 of 2 residents (Resident #16) reviewed for access of records. [...]

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician, and notify, consistent with his or her authority, the resident's representative when there was a significant change in the resident's physical, mental, or psychosocial status, that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 2 residents (Resident #16) reviewed for notification of changes. The facility failed to notify Resident #16's physician when Resident #16 had a change in condition on 11/22/24. This failure could place residents' at risk of a delay in treatment and decline in the residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had a right to personal privacy and confidentiality of his or her personal and medical records for 1 of 4 residents (Resident #17) reviewed for privacy and confidentiality. The facility failed to ensure LVN BB logged out of her computer and protected Resident#17's Medication Administration Record. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to medication administration records being accessible to others.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan each residnet that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 1 of 2 resident's (Resident #108) reviewed for baseline care plans. The facility failed to ensure Resident #108's weight bearing status to her fractured right arm was addressed on the baseline care plan. This failure could place residents at risk of increased pain, and worsening of fractures.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for1 of 2 residents (Resident #37) reviewed for Care Plans. The facility failed to update Resident #37's Care Plan to reflect a history of Staph dermatitis (an infection caused by staphylococcus bacteria) with interventions for the antibiotic use and the staff to monitor the resident for possible Staph symptoms. This deficient practice could place residents at risk of not receiving the care and services they needed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 2 of 57 residents (Resident #14 and Resident #31) reviewed for respiratory care. 1. The facility failed to ensure Resident #14's oxygen was administered at 3 liters per minute via nasal cannula as prescribed by the physician. 2. The facility failed to ensure Resident #31's oxygen was administered at 4 liters per minute via nasal cannula as prescribed by the physician. This failure could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were only accessible by authorized personnel, for 1 of 6 medication carts (400 hall medication cart) observed for medication storage. The facility did not ensure the 400-hall medication cart was secured and unable to be accessed by unauthorized personnel. This deficient practice could place residents at risk for harm due to improper storage and drug diversion.

Inspectors wroteBased on interviews and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 7 residents (Resident #48 and Resident #12) reviewed for laboratory services. 1. The facility failed to ensure Resident #48's lipid level (a blood test that measures the levels of different fats in your blood. The test can help identify abnormalities in your blood lipids and determine your risk for certain diseases, including heart disease and stroke) was drawn on 08/14/24. 2. The facility failed to obtain Resident #12's ordered Hgb A1C (hemoglobin A1C measures blood glucose level). These failures could place residents at risk of not receiving lab services as ordered, not receiving timely diagnosis and treatment, and not receiving appropriate monitoring for certain diseases.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure professional staff were certified in accordance with applicable State laws for 1 (NA EE) of 15 personnel reviewed for licensed nursing. The facility failed to ensure NA EE had become a Certified Nurse Aide by passing her certification test. This failure could place residents at risk of being provided care by staff who were not qualified per state law.

Inspectors wroteBased on interviews and record review the facility failed to arrange an appointment with an outside resource for 1 of 1 resident (Resident #108) reviewed for the use of outside resources. The facility failed to ensure Resident #108's appointment for the orthopedic specialist (specialty for prevention, diagnosis, and treatment of disorders, conditions, and injuries of the skeleton and its associated structures, including muscles, ligaments, joints, and tendons) was made for her right arm fracture. This failure could place residents at risk of not receiving needed medical care.

Inspectors wroteBased on interviews and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 7 residents (Resident #38) reviewed for hospice services. The facility failed to maintain Resident #38's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, and physician recertification. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 6 residents (Resident #1 and Resident #2) reviewed for resident rights. CNA B did not treat Resident #1 and Resident #2 with dignity or respect when she spoke to them in a rude tone. This failure could place residents at an increased risk of embarrassment, anger, feelings of worthlessness, sadness, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 3 of 22 residents (Resident's #4, #36, and #42) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #4, Resident #36, and Resident #42, who complained the food was served cold, was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for 2 of 2 meals (Lunch meal on 11/13/23 and 11/14/23) observed for frequency of meals. The facility did not serve the 11/13/23 and the 11/14/23 lunch meal at the scheduled time. This failure could place residents at risk for decreased meal satisfaction, decreased intake, loss of appetite, side effects from medication given without food, and diminished quality of life.

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 safety in the facility's only kitchen. The facility did not ensure: 1. DA E wore a hair net while in the kitchen. 2. Paper towels were readily available at the handwashing sink. 3. Meat was thawing in the appropriate container and sink. 4. Food preparation areas were kept clean and free of crumbs and dirty dishes. 5. The refrigerator was kept at the appropriate temperature. 6. The refrigerator was not leaking condensation. 7. The refrigerator was free of foul-smelling rotting odors. 8. The containers in the refrigerator were labeled, dated, and not expired. 9. Eggs were not cracked. 10. The frozen packages in the freezer were labeled and dated. 11. The can opener tip, microwave, and fryer were kept clean. 12. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practices for 3 of 9 residents (Residents #10, #21 and #115) reviewed for respiratory care. 1. The facility did not ensure Resident #10 and Resident #21's oxygen concentrator filters were cleaned. 2. The facility did not ensure Resident #21's oxygen was set at 3 LPM as ordered by the physician. 3. The facility did not ensure Resident #115's oxygen was set at 2 LPM as ordered by the physician. These failures could place residents who receive respiratory care at risk for developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on interviews and record review, the facility failed to act upon the recommendations of the pharmacist report of irregularities for 1 of 5 residents (Resident #4) reviewed for (DRR) Drug Regimen Review. 1. The facility failed to timely implement Resident #4's signed Note to Attending Physician/Prescriber on 10/12/23, which agreed with the pharmacy recommendation to schedule Resident #4's antianxiety medication. 2. The facility failed to timely implement Resident #4's signed Note to Attending Physician/Prescriber on 10/12/23, which agreed with the pharmacy recommendation for a gradual dose reduction on an antidepressant medication. This failure could place residents at risk for receiving unnecessary medications at the most effective dosage.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs and the facility failed to have target behavioral monitoring in place for behaviors associated with the use of psychotropic medications documented in the clinical record for 3 of 5 (Resident's #4, #10, and #36) reviewed for unnecessary medications. 1. The facility failed to ensure Resident #4 received a gradual dose reduction of his anti-depressant medication. 2. The facility did not ensure a clinical rationale for declination of a GDR was documented by the physician for Resident #10. 3. The facility did not ensure Resident #36's behaviors were adequately monitored regarding her antianxiety, and antidepressant medications. 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #56) reviewed for infection control practices related to transmission-based precautions and 1 of 3 facility staff members (MA B) reviewed for infection control practices related to medication pass. 1. The facility did not ensure Resident #56 had an order for isolation precautions and appropriate signage outside the door to alert staff and visitors of isolation status and appropriate PPE to wear inside Resident #4's room. 2. The facility did not ensure MA B disinfected the manual blood pressure monitor and stethoscope between Resident #52, #41 and #20. [...]

Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 22 (Residents #61) residents reviewed change of condition. The facility did not ensure Physician D was notified when Resident #61 was exhibiting suicidal ideation on 11/12/23. This failure could place residents at risk of a delay in treatment or interventions, worsening of their physical and psychological condition, and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete Quarterly MDS assessment was transmitted to the CMS System within 14 days after completion for 1 of 22 residents (Resident #54) reviewed for MDS assessments. The facility did not ensure Resident #54's Quarterly MDS assessment, dated 09/27/2023, and completed on 09/28/2023, was transmitted within 14 days of completion. This deficient practice could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on interview, and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, and mental and psychosocial needs identified in the comprehensive assessment for 2 of 22 residents (Residents #20 and #59) reviewed for care plans. 1. The facility did not develop Resident #20's care plan related to him being PASRR positive effective 04/01/2023. 2. The facility did not develop Resident #59's care plan related to Hepatitis C (infection caused by a virus that attacks the liver and leads to inflammation) effective 10/06/2023. These failures could place residents at risk for unmet care needs and decreased quality of 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 services to maintain personal hygiene for 2 of 64 (Residents #10 and #21) residents reviewed for ADLs. 1. The facility failed to ensure Resident #10's fingernails were trimmed routinely. 2. The facility did not ensure Resident #21's fingernails were trimmed and free from a brown colored substance routinely. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to provide mentally related social services to attain or maintain the highest practicable mental and psychosocial well-being for 1 of 1 (Resident #61) residents reviewed for social services. 1. The facility failed to ensure the Social Worker was notified and social services were provided after Resident #61 exhibited suicidal ideations on 11/12/23. 2. The facility failed to ensure Resident #61 received a psychiatric referral after he exhibited suicidal ideations on 11/12/23. These failures could place residents at risk for their mental and psychosocial needs not being met and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services to determine that drug records are in order and that an account of all controlled drugs was maintained and periodically reconciled for 2 of 4 medication carts (North and [NAME] Hall) and 1 of 5 residents (Resident #20) reviewed for pharmacy services. 1. The facility did not ensure Resident #20's lactobacillus 0.2 mg (medication that is used to prevent or treat infections in children and adult) as ordered by the physician was administered instead of the lactobacillus 10 mg. 2. The facility did not ensure LVN M counted controlled drugs every shift change on 11/02/2023 and 11/05/2023. These failures could result in an inaccurate controlled medication count, drug diversion, and decreased therapeutic effects from medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 22 residents (Resident #10) reviewed for laboratory services. The facility did not obtain a physician's ordered Hgb A1c (a blood test that measures the average blood sugar levels over the past three months) for Resident #10. This failure could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level.

Inspectors wroteBased on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 2 residents (Residents #3) reviewed for antibiotic use. The facility failed to assess and incorporate monitoring of antibiotic use for Resident #3. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow their established smoking policy for 1 of 1 smoking area reviewed for smoking. The facility did not ensure smoked cigarettes were extinguished in a fire-retardant receptacle. This failure could place residents at risk for smoking-related injuries and fires in the facility.