Terrell Healthcare Center

Inspectors wroteBased on interviews and record review, the facility failed to designate an Infection Preventionist that was qualified by education, training, experience, or certification, and who completed specialized training in infection prevention and control, for one of one facility. The facility did not designate a qualified Infection Control Preventionist. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 9 of 12 (Resident #19) residents reviewed for privacy and confidentiality.1. The facility failed to ensure LVN K logged out of her computer and protected Resident#19's Medication Administration Record. 2. The facility did not ensure residents had the right to promptly receive mail on Saturdays. 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 coordinate with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability or a related condition received care and services in the most integrated setting appropriate to their needs for 4 of 6 residents (Resident #41, Resident # 25, Resident #11, and Resident #9) reviewed for PASRR. 1. The facility failed to coordinate with the appropriate state authority to ensure Resident #41 who had a mental disorder received a PASRR meeting (to see if she would qualify for other care and services) after she was positive on her PE on 01/12/26. 2. The facility failed to provide documentation of Resident #25's habilitation coordination and independent living skills services as requested in the PCSP Form.3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate treatment and service of care for 3 of 3 residents (Residents #8, #23, and #70) reviewed for indwelling catheter. 1. The facility failed to ensure Resident #8's foley catheter (tube inserted into bladder) was secured on 03/31/26. 2. The facility failed to ensure Resident #23 had his catheter secured on 03/31/26 and 04/01/26. 3. The facility failed to have an appropriate diagnosis or indication for the use of the indwelling catheter for Resident #70. These failures could place residents at risk for urinary tract infections and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 medication room (hall 100) refrigerator for 2 of 2 residents (Resident #54 and Resident #39), 1 of 3 medications carts(hall 300) for 1 of 3 residents (Resident #5), and for 2 of 24 residents (Resident #16 and Resident#23) reviewed for medication storage.1. The facility failed to ensure Resident #54's Lorazepam (antianxiety medication) and Morphine (pain medication) were secured behind two locks2. The facility failed to ensure Resident #39's Morphine (pain medication) was secured behind two locks.3. The facility failed to ensure an insulin pen was dated when opened on the 300-hall medication cart.4. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 8 of 8 confidential residents, and 1 of 1 meal was reviewed for palatability, attractiveness, and appetizing. The facility failed to provide food that was palatable and at an appetizing temperature for 8 confidential residents for lunch on 4/1/26. These failures could place residents at risk of decreased food intake, hunger, and unintended weight loss. Findings Included:In a Resident Council Meeting on 4/1/2026 at 10:00 am, 8 of 8 residents said the food was bland and served warm. During an observation on 4/1/26 at 12:48 pm the last food temperature was checked on the warming table, trays prepared, and service began at 12:52 pm. The test tray was prepared at 12:59pm. [...]

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 only kitchen reviewed for food safety requirements. 1. The facility failed to ensure the grease in the fryer was fresh and free of burnt food particles floating in it. 2. The facility failed to ensure the bags of food in the refrigerator were used or disposed of by the expiration date according to facility policy. 3. The facility failed to ensure the juice nozzle had no black film inside per facility policy. 4. The facility failed to ensure employees in the kitchen wore hair nets according to facility policy.5. The facility failed to ensure employees in the kitchen wore beard guards according to facility policy. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure resident were treated with respect, dignity, and care in a manner and in an environment, that promotes maintenance or enhancement of her quality of life, for 1 of 6 residents reviewed for dignity issues (Resident #70). The facility failed to ensure they had a privacy bag for Resident #70's indwelling catheter. This failure could place residents at risk of feeling uncomfortable, increase anxiety and loss of dignity. Record review of Resident #70's face sheet, dated 04/03/26 indicated she was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses which included, Chronic obstructive pulmonary disease also known as COPD (lung and airway diseases that restrict your breathing), diabetes ( a condition that happens when your blood sugar (glucose) is too high), and high blood pressure. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure the resident had the right to be informed of and participate in his or her treatment for 1 of 6 residents (Resident #9) reviewed for consents. The facility failed to obtain informed consent from Resident #9 for the antipsychotic Zyprexa (Olanzapine) to be administered starting on 1/25/26. The facility's failure to obtain and document informed consent for antipsychotic medication places the resident at risk for unnecessary chemical restraint, adverse side effects, and violation of the resident's rights to make informed decisions regarding their care and treatment.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure the resident had a right to reasonable accommodations of resident needs for 1 of 8 residents (Resident #64) reviewed for accommodations of needs for call light availability. The facility failed to ensure Resident #64's call button was within reach. This failure could place residents at risk of a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 24 residents (Resident #48) reviewed for MDS assessment accuracy. The facility failed to code Resident #48's quarterly MDS dated [DATE] with the primary language of Spanish. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the services provided or arranged by the facility, as outlined by the comprehensive care plan were provided by qualified persons in accordance with each resident's written plan of care for 1 of 6 residents sampled (Resident #23). The facility failed to ensure CNA B did not apply triad hydrophilic wound dressing paste (a medication cream to manage chronic wound, pressure ulcers, and dermal lesions) to bilateral buttocks of Resident #23 without qualifications to do so. This failure could place residents at risk for not receiving appropriate care and treatment outlined in their comprehensive care plan.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish based on the comprehensive assessment and consistent with the resident's needs and choices for 2 of 2 residents (Residents #48 and #46) reviewed for activities of daily living. The facility failed to provide communication assistance to effectively communicate with staff for Residents #48 and #46. These failures could place residents at risk for declining and diminishing quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide residents with limited range of motion appropriate treatment and services to increase range of motion and to prevent further decrease in range of motion for 1 of 10 residents (Resident #14) reviewed for range of motion. The facility did not ensure Resident #14 wore a left wrist roll (a device to prevent further decline in an extremity contracture) on 03/31/26, 04/01/26 and 04/02/26. This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, 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, the comprehensive person-centered care plan, and the resident's goals and preferences for 2 of 3 residents (Resident #70 and Resident #47) reviewed for respiratory care.1. The facility failed to ensure Resident #70, and Resident #47 had a physician order for the use of oxygen.2. The facility failed to ensure Resident #47's oxygen concentrator filter was clean. 3. The facility failed to ensure Resident #47 had the use of oxygen included on her care plan. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 1 residents (Resident #9) reviewed for trauma-informed care. The facility failed to ensure Resident #9 had physician's orders for monitoring post-traumatic stress disorder behaviors The facility did not ensure Resident #9's care plan reflected a diagnosis of post-traumatic disorder and included interventions for post-traumatic stress disorder behaviors This failure could put residents at an increased risk for severe psychological distress due to re-traumatization. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, dispensing, administering and reconciliation to determine that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled of all drugs and biologicals) for 1 of 1 storage area, and 1 of 2 medication rooms (hall 100) reviewed for pharmacy services.1. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. 2. The facility failed to ensure staff counted narcotic medication in the refrigerator on hall 100 medication room which contained Lorazepam (antianxiety medication) and Morphine (pain medication). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs 2 of 24 residents (Residents #14 and #18) reviewed for laboratory services. 1. The facility did not obtain a physician's ordered Tegretol level (to measure the medication's level in the blood to ensure it is within a safe, therapeutic range) for Resident #14. 2. The facility did not obtain a physician's ordered Vitamin D level (to measure the level of vitamin D in the blood, identifying deficiencies that can cause bone weakness, soft bones (osteomalacia), or fractures) for Resident #18. These failures could place residents at risk of not receiving lab services as ordered and not managing medications at a therapeutic level.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident receives and the facility provides food that accommodates residents' food preferences for 1 of 24 residents (Resident #18) reviewed for food preferences and the accommodation of resident's meal choices. The facility did not honor Resident #18's preference for double vegetables. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs and as prescribed by the physician for 1 of 24 residents (Resident #18) reviewed for therapeutic diets. The facility did not ensure Resident #18 was given double protein portion as ordered by the physician. This failure could place residents at risk for poor intake, weight loss, unmet nutritional needs, and a loss of dignity. Findings Included: Record review of Resident #18's face sheet, dated 04/03/26, reflected Resident #18 was a [AGE] year-old female, admitted to the facility on [DATE] with diagnoses which included Vitamin D deficiency (inadequate levels of Vitamin D) and unspecified severe protein-calorie malnutrition. [...]

Inspectors wroteBased on interview and record review the facility failed to collaborate with hospice representatives and coordinating long term care facility staff participation in the hospice care planning process for those residents receiving hospice services, and communicating with hospice representatives and other healthcare providers participating in the provision of care for the terminal illness, related conditions, and other conditions, to ensure quality of care for the patient and family for 1 of 2 resident (Resident #9) reviewed for hospice services. The facility failed to obtain and ensure Resident #9's most current Hospice Plan of Care/ Interdisciplinary Group Reports, Medication Report, and Physician Orders were part of the current clinical record. The facility failed to ensure Resident #9's hospice medication regimen paired with the facility's medication regimen. [...]

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 5 residents (Resident #18) reviewed for infection control. The facility did not ensure LVN O discarded dirty linen properly while providing wound care to Resident #18. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (200 hall Nurse Medication Cart and 200 hall Medication Aide Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure MA A properly stored a medication card of gabapentin 300 mg capsules, when she left it on top of the medication cart unattended on 03/04/2026. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing and administering of all drugs and biologicals, to meet the needs of each resident and determined that drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 2 of 3 residents (Resident #2 and Resident #1) reviewed for pharmacy services. The facility failed to ensure MA A administered Resident #2's buspirone 5 mg (medication used to treat anxiety) as ordered by the physician. The facility failed to ensure Resident #1's sertraline 100 mg (medication used to treat depression) was removed from the medication cart after it was discontinued on 01/28/2026. [...]

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 3 residents (Resident #1) reviewed for infection control. The facility failed to ensure CNA D used the proper PPE for droplet precautions (face shield and face mask) while in Resident #1's room and removed it prior to exiting Resident #1's room on 03/04/2026. The facility failed to ensure MA A used the proper PPE for droplet precautions (face shield) when administering medications to Resident #1 and removed it prior to exiting Resident #1's room on 03/04/2026 and 03/05/2026. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis services were provided consistently with professional standards of practice for 1 of 2 residents reviewed for dialysis services. (Resident #7) The facility did not provide ongoing assessments after Resident #7's dialysis treatments and did not keep ongoing communication with the dialysis facility. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 13.33%, based on 4 errors out of 30 opportunities, which involved 2 of 5 residents (Resident #50 and Resident #52) and 1 of 1 staff (MA F) reviewed for medication administration. 1. The facility failed to ensure MA F administered Resident #50's amantadine (medication used to treat stiffness, tremors, or uncontrolled movements), escitalopram (medication used to treat depression), and aripiprazole (medication used to treat mental illnesses) on 12/02/2025. 2. The facility failed to ensure MA F administered Resident #52's carvedilol (medication used to treat heart failure and high blood pressure) with meals as ordered by the physician on 12/02/2025. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure all drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable and failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 3 of 6 residents (Resident #7, Resident #50 and Resident #52) reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #50's medication labels for her famotidine, aripiprazole (medication used to treat mental illnesses), and amantadine (medication used to treat stiffness, tremors, or uncontrolled movements) matched her physician order. [...]

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with appropriate competencies and skills to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 3 of 8 dietary staff (Cook N, [NAME] O, and Kitchen Aide P) reviewed for food and nutrition services. The facility failed to ensure dietary staff (Cook N, [NAME] O, and Kitchen Aide P) serving in the kitchen maintained a current Food Handler Certificate. This failure could place residents at risk of causing foodborne illnesses or infection.

Inspectors wroteBased on observation and interview [TF1] the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen [TF2] meal (lunch) [TF3] and 3 of 22 residents (Resident #35, Resident #4, and Resident #40) reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 12/01/25 at lunch. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

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 3 of 4 residents (Resident #7, Resident #27 and Resident #45) reviewed for infection control. 1. The facility failed to ensure Resident #45 had proper signage for contact isolation precautions posted and her order specified the type of isolation precaution she required. 2. The facility failed to ensure CNA B and CNA L provided proper incontinent care to Resident #27 and failed to ensure CNA B performed hand hygiene during the incontinent care on 12/02/2025. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs for 3 of 6 (Resident #2, Resident #55, and Resident #40) residents reviewed for care plans. 1. The facility failed to care plan for Resident #2's hydroxyzine (medication used to treat anxiety), which started on 08/01/25. 2. The facility failed to care plan the removal of Resident #55's supervised smoking to unsupervised smoking on 3/3/25. 3. The facility failed to care plan the removal of Resident #40's tracheostomy size 7.0 trach to size 6.0. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interview and record review, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #10) reviewed for activities. The facility failed to ensure quarterly activity assessments were completed for Resident #10 and to provide activities to meet their low-functioning needs. 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 observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 2 (Resident #10) residents reviewed for range of motion. The facility failed to ensure Resident #10's wrist roll (medical device used to treat hand contractures, permanent tightening of the muscles, tendons, skin and surrounding tissues that cause stiffness, placed in the hands to help improve range of motion) was in place to his left hand. The facility failed to implement a medical device for Resident #10's left hand to help improve range of motion. The failures could place residents at increased risk for decrease in mobility and range of motion and contribute to worsening of contractures.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents' environment remained free of accident hazards for 1 of 22 residents (Resident #7) reviewed for accident hazards. The facility failed to ensure Resident #7's was transferred with the mechanical lift using 2 staff members throughout the entire transfer. This failure could place residents at risk for injuries.

Inspectors wroteBased on observation, interview, 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, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 3 residents (Resident #40) reviewed for respiratory care. 1. The facility failed to have an extra tracheostomy in Resident #40's room. 2. The facility failed to ensure Resident #40's oxygen was set at 4 liters per nasal cannula as ordered on 12/01/25 and 12/02/25. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

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 5 residents (Resident #50) reviewed for pharmacy services. The facility failed to ensure Resident #50's escitalopram oxalate 5 mg (medication used to treat depression) was removed from the medication cart after it was discontinued on 09/26/2025. This failure could place residents at risk of receiving medications that were not ordered and medication errors.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish polices in accordance with applicable Federal, State and local and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 2 of 4 residents (Resident #2 and Resident #55) reviewed for smoking. The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #2 and Resident #55. This failure could place residents at risk of unsafe smoking and injury.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the PASRR program, including incorporating the recommendations from the PASRR evaluation report into a resident's care planning for 1 of 3 residents reviewed for PASRR assessments. (Resident #1) The facility did not provide and arrange for a specialized mattress for Resident #1 as recommended and agreed upon by the IDT on 6/10/25 within the time frame set by PASRR. This failure could place residents who are PASRR positive at risk of not receiving the necessary services/DME that would enhance their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility training was completed for 1 of 11 employees (LVN C) reviewed for training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by LVN C annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 3 of 11 employees (RN A, CNA B, and LVN C) reviewed for training. The facility did not ensure QAPI annual training was completed by RN A, CNA B, and LVN C. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure Compliance and Ethics training through an effective way to communicate the program's standards, policies, and procedures through a training program or in another practical manner which explains the requirements under the program was completed for 1 of 11 employees (RN A) reviewed for training. The facility did not ensure annual Compliance and Ethics training was completed by RN A. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right of the residents to be free from abuse for 1 of 23 residents (Resident #45) reviewed for abuse. The facility failed to protect Resident #45 when an allegation of abuse occurred when RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself on 03/20/2025. The facility failed to protect Resident #45 from abuse when RN A, RN D, and the DON demonstrated to Resident #45 how she should hit her head on the wall to injure herself. The facility failed to prevent abuse when RN A, RN D, the DON, MA C, and MA B laughed at Resident #45 for banging her head on the wall, while she was in emotional distress. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 1 of 23 residents (Resident #45) reviewed for abuse. The facility failed to ensure Housekeeper E reported an allegation of abuse immediately to the Abuse Coordinator on 03/19/2025 due to fear of retaliation. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source, and misappropriation of resident property were thoroughly investigated for 1 of 23 residents (Resident #45) reviewed for abuse. The facility failed to investigate/protect/correct when an allegation of abuse allegedly occurred when RN A told Resident #45 to bang her head on the corner of the wall and maybe it would knock her brain out and she would kill herself on 03/20/2025 and prevent potential abuse when RN A, RN D, and the DON demonstrated to Resident #45 how she should hit her head on the wall to injure herself. The facility failed to prevent potential abuse when RN A, RN D, the DON, MA C, and MA B laughed at Resident #45 for banging her head on the wall, while she was in emotional distress. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received the necessary behavioral health care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care for 1 of 3 residents (Resident #45) reviewed for behavioral services. The facility failed to provide Resident #45 with additional psychiatric services until 3/24/25 when the surveyor Intervened. The facility failed to document Resident #45's behaviors on the EMAR accurately reflecting her behavioral status. The facility failed to review and revise Resident #45's care plan to implement interventions to prevent self-harm when Resident #45's behavior of hitting her head increased on 03/24/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all 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, for 1 of 23 residents (Resident #45) reviewed for abuse and neglect reporting. The facility failed to ensure Housekeeper E reported an allegation of abuse immediately to the Abuse Coordinator on 03/19/2025 due to fear of retaliation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment was as free of accident hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 of 8 residents (Resident #45) reviewed for accidents and hazards. The facility failed to ensure Resident #45 did not smoke a cigarette in the facility on 03/25/25 at 8:38 AM and did not implement measures to prevent another occurrence. The facility failed to ensure Resident #45 did not smoke a cigarette in the facility on 03/25/25 at 12:57 PM The facility failed to ensure Resident #45 was reassessed for smoking safety after she lit a cigarette inside the facility on 3/25/25 until after the second time she was found smoking inside the facility. The facility failed to notify the NP or the physician of Resident #45 smoking in the facility. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure pain management was provided to residents who required such services consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 23 residents (Resident #72) reviewed for pain management. 1. The facility did not ensure that effective pain management was provided to the resident. 2. The facility did not ensure RN S acknowledged Resident #72's pain when she was yelling, prior to, during and after wound care. 3. The facility did not ensure RN S evaluated Resident #72's pain during wound care. 4. The facility did not ensure RN S effectively managed Resident #72's pain prior to her receiving wound care. 5. [...]

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 safety in the facility's only kitchen. The facility did not ensure: 1. Food items were labeled and dated. 2. [NAME] PP removed her gloves prior to touching the refrigerator. 3. The juice machine spigot was free from a red/orange gooey substance where the juice was dispersed. 4. Fryer was free from debris. 5. The dome covers, and pureed plates were stacked with water pooled in between them. 6. Bleach noted on top of the corn meal bin. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, 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 2 of 4 residents (Resident #23 and Resident #35) reviewed for treatment and services related to indwelling catheters. 1. The facility failed to ensure Resident #23's foley catheter was secured on 03/24/2025. 2. The facility failed to ensure Resident #35's foley catheter care was provided as ordered. This failure could place residents at risk for urinary tract infections and a decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents who were trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 3 of 23 residents (Resident #68, Resident #127, Resident #45) reviewed for trauma-informed care. 1. The facility failed to ensure Resident #45 had a social history assessment completed upon admission to determine if she had any trauma or triggers. 2. The facility did not ensure Residents #68's and #127's care plans identified possible triggers when Residents #68 and #127 had a history of trauma. 3. The facility did not ensure trauma screenings were completed upon admission to the facility for Residents #68 and #127. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 2 of 23 residents (Resident #43 and Resident #72) and 2 of 8 medication carts (200 hall Nurse Medication Cart and 300 hall Nurse Medication Cart) reviewed for drugs and biologicals. 1. The facility failed to ensure LVN F secured the 200 hall Nurse Medication Cart, when it was not in use on 03/25/2025. 2. The facility failed to ensure Resident #43's insulin was properly secured when RN R left it on top of the 300 hall Nurse's Mediation Cart on 03/25/25. 3. The facility failed to ensure RN secured the 300 hall Nurse Medication Cart, when she went in Resident #43's room to administer her insulin on 03/25/25. 4. [...]

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 2 of 5 residents (Resident #23 and Resident #72) reviewed for infection control. 1. The facility failed to ensure CNA G followed enhanced barrier precautions, performed hand hygiene and proper glove changes while providing incontinent care to Resident #23 on 03/24/2025. 2. The facility did not ensure EBP were put in place for Resident #72. 3. The facility did not ensure RN S performed hand hygiene while providing wound care to Resident #72. These failures could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 23 residents (Resident #18) reviewed for reasonable accommodations. The facility failed to ensure Resident #18's call light was within reach while in bed. This failure could place residents at risk for a delay in assistance and a decreased quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 1 of 23 residents (Resident #72) reviewed for advanced directives. The facility did not ensure Resident #72 had documentation of their advanced directive on file in their records. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment for 2 of 4 residents (Resident #5 and Resident #17) reviewed for resident rights. The facility failed to ensure Resident #5's and Resident #17's bathroom had running hot water, did not have a loose faucet and the toilet tank was not leaking. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to refer residents for PASRR screening and evaluation with mental health disorders for level II PASRR review for 1 of 6 residents (Resident #26) reviewed for PASRR. The facility did not ensure Resident #26 was referred to the state-designated authority for PASRR evaluation when readmitted to the facility on [DATE] with a positive PL1 within 7 days of notification. This failure placed residents at risk of not receiving adequate services or care related to mental illnesses.

Inspectors wroteBased on record review and interviews, the facility failed to ensure completion of a discharge summary including a recapitulation of the resident's stay, and final status at discharge for 1 of 3 residents (Resident #76) reviewed for discharge summary. The facility failed to ensure Resident #76's discharge summary was accurately completed. This failure could place residents at risk of not having complete records after permanent discharge from the facility.

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 grooming and personal hygiene for 1 of 2 residents reviewed for ADLs. (Resident #35) 1. The facility failed to ensure Resident #35's nails were trimmed and cleaned. This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents maintained acceptable parameters of nutritional status for 1 of 5 residents reviewed for unplanned weight loss. (Resident #2) The facility failed to ensure a weight variance was addressed and documented to ensure management of weight loss for Resident #2. This failure could place residents at risk for undetectable weight loss, malnutrition, and poor quality of life.

Inspectors wroteBased on observation , interview and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice for 1 of 2 residents (Resident #35) reviewed for parenteral fluids. The facility failed to ensure the dressing on Resident #35's midline (a thin, flexible tube inserted into a vein in the upper arm, used for short-term intravenous therapies and blood sampling) was changed weekly. These failures could affect residents by placing them at risk for infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents who require dialysis services receive such services consistent with professional standards of practice for 1 of 2 resident reviewed for dialysis services. (Resident #20) The facility did not provide ongoing assessments before and after Resident #20's dialysis treatments and did not keep ongoing communication with the dialysis facility. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interviews and record review the facility failed to ensure residents who use psychotropic drugs receive gradual dose reductions, unless clinically contraindicated, to discontinue these psychotropic drugs for 2 of 23 (Residents #26 and #7) reviewed for unnecessary medications. 1. The facility did not ensure a clinical rationale for declination of a GDR was documented by the physician for Resident #26 on 02/26/25. 2. The facility failed to ensure an attempt for a gradual dose reduction or clinical rationale was performed for the medication Trazadone 150mg tab every night, originally ordered on 06/04/24 for Resident #7 when the pharmacist provided a recommendation on 02/26/25. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed provide sufficient support personnel to safely and effectively carry out the functions of the food and nutrition service for 2 out of 7 dietary staff. The facility did not ensure [NAME] N and Dietary Aide X had a current food handler permit. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies.

Inspectors wroteBased on observation, interview, and record review the facility failed to accommodate residents' food allergies for 1 of 23 residents (Resident #64) reviewed for food allergies. The facility failed to honor Resident #64's food allergy to peaches. This failure could result in allergic reactions, a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 3 of 23 residents (Residents #51, #26) reviewed for resident records 1. The facility failed to ensure Resident #51's care plan was updated and revised to reflect her smoking status. 2. The facility did not ensure Resident #26's catheter care was documented. 3. The facility did not ensure Resident #72's wound care was documented. These failures could place the resident at risk for not receiving appropriate care due to incomplete/inaccurate information being documented.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide and document an effective discharge planning process that focused on the resident's discharge goals, the preparation of residents to be active partners and effectively transition them to post-discharge care, and the reduction of factors leading to preventable readmissions for 1 (Resident #1) of 3 residents reviewed for discharges. The facility failed to ensure Resident #1 had a safe discharge leading to his hospitalization and threats of suicide on 03/08/24. An IJ was identified on 03/19/24. The IJ template was provided to the facility on [DATE] at 4:40 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to complete a discharge summary that included but was not limited to, (i) A recapitulation of the resident's stay that includes, but was not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results; (ii) A final summary of the resident's status; (iii) Reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over-the-counter) for 3 of 5 residents (Residents #1, #2 and #3) reviewed for discharge summaries. The facility failed to write an order for discharge, complete a discharge summary, and a reconciliation of medications for Resident #1 when he was discharged on 03/08/24. The facility failed to write an order for discharge and complete a discharge summary for Resident #2 and Resident #3. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify a representative of the Office of the State Long-Term Care Ombudsman, for 1 of 3 residents (Resident #1) reviewed for discharge. The facility initiated a 30-day discharge for Resident #1 on 03/06/24 and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right of the residents to be free from abuse for 3 of 6 residents (Resident's #23, #43, and #56) reviewed for abuse. 1. The facility failed to protect Resident #56 from physical abuse from Resident #25 on 01/27/2024. Resident #56 stated he did not feel safe in the facility. 2. The facility failed to protect Resident #23 from Resident #25 after the occurrence of physical abuse on 04/11/2023. Resident #23 stated she did not feel safe in the facility. 3. The facility failed to protect Resident #43 from misappropriation from Resident #25 on 01/27/2024. 3a. The facility failed to ensure Resident #43 did not stay in the room with Resident #25 after Resident #25 took his money, and Resident #43 expressed desire to relocate due to feeling fearful of Resident #25. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 3 of 6 residents (Resident's #23, #43, and #56) reviewed for abuse. 1. The facility did not implement the policy by providing ongoing monitoring and interventions for Resident #25 when he had a history of physical aggression and taking others personal property. 2. The facility did not implement the policy to keep Resident's #23, #43, and #56 safe from further abuse. An Immediate Jeopardy (IJ) was identified on 02/12/2024 at 1:53 PM. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to follow their own established smoking policy for the 1 of 1 smoking area reviewed for smoking policies. 1. The facility failed to ensure Resident's #56 and Resident #16 were supervised and wore a smoking apron during the smoking times. 2. The facility failed to ensure Resident #21 was supervised during the smoking times. 3. The facility failed to ensure Resident #5, and Resident #21 did not keep their smoking materials in their room. 4. The facility failed to ensure Resident #25 was re-assessed for smoking safety after he lit a cigarette in the building on 01/12/2024. 5. The facility failed to ensure cigarette butts were disposed of properly. An IJ was identified on 02/12/2024 at 1:53 PM. [...]

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 21 residents (Resident #36 and Resident #46) reviewed for resident rights. 1. The facility did not ensure Resident #36's catheter drainage bag was in a privacy bag. 2. The facility did not ensure CNA T waited for a response from Resident #46 after knocking on his door, before entering his room. These failures could place residents at an increased risk of embarrassment and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 5 of 5 confidential residents reviewed for weekend mail delivery. The facility failed to ensure residents received their mail on the weekend. This failure could place residents at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 4 halls (100-hall) and 3 of 4 residents (Resident #38, Resident #3, and Resident #51) reviewed for a homelike environment. 1. The facility failed to ensure the 100-hall was free of offensive odors. The facility failed to ensure Resident #38's wall and door frame were repaired. The facility failed to maintain comfortable sound levels for Resident #38. 2. The facility failed to replace Resident #3's mattress. 3. The facility did not ensure Resident #51's privacy curtain was cleaned. These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 4 of 21 residents (Resident #4, Resident #5, Resident #38, and Resident #54) reviewed for grievances. 1. The facility failed to act upon Resident #54's grievance regarding his motorized wheelchair not functioning. 2. The facility did not ensure a grievance was filed for Resident #4's pair of large men's black sweatpants and 1 blue shirt with embroidery when they were not returned from the laundry. 3. The facility did not ensure a grievance was filed for Resident #38's 2 blue shirts and 6 blankets when they were not returned from the laundry 4. The facility failed to resolve Resident #5's grievance. Resident #5 reported $100 dollars missing since September 25, 2023. Resident #5 filed a grievance but was never notified of the outcome. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 3 of 3 resident (Residents #212, #19 and #30) reviewed for pharmacy services and 5 of 6 (100, 200, and 300 Hall) medication carts reviewed for storage of medications. 1. Three disposable medicine cups of pills were stored at bedside of Resident #212. 2. Treatment Medication Cart for Hall 200 was left unlocked, unsecured, and unattended near the nurse station. 3. RN OO failed to ensure the medication cart was locked when medication cart was left unattended on 2/12/24. 4. The facility did not ensure LVN F locked the treatment cart on 200 Hall, while providing treatment care. 5. The facility did not ensure RN O locked the medication cart on 100 Hall, while administering medication. 6. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually for 1 of 1 facility. 1. The facility did not update the facility assessment to include Resident #19's tracheostomy (surgically created hole in the windpipe that provides an alternative airway for breathing) and bariatric status. 2. The facility did not update the facility assessment to include Resident #53 who was receiving IV antibiotics. 3. The facility did not update the facility assessment to include Resident #8, #13 and #30's G-tube (tube inserted through the wall of the abdomen directly into the stomach). These failures could affect residents by not having the necessary resources to ensure appropriate care is provided.

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 4 of 5 residents (Resident #19, Resdient #55, Resident #30, and Resident #50) and 6 of 8 staff (CNA U, CNA BB, Laundry Aide SS, RN O, LVN P, and LVN F) in the facility reviewed for infection control practices and transmission-based precautions. 1. The facility failed to ensure CNA U and CNA BB performed hand hygiene after removing their gloves while providing incontinent care to Resident #19. The facility failed to ensure CNA BB did not transport linens unbagged. The facility failed to ensure Laundry Aide SS kept the clean laundry cart covered when delivering clothes. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 2 residents (Resident #111) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #111 was given a NOMNC (is a notice that indicates when your care is set to end from a home health agency, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice) when discharged from skilled services prior to his covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.

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 of 21 residents (Residents #19) reviewed for ADL care. The facility failed to ensure Resident #19 was provided thorough bed baths. This failure 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 an ongoing program of activities in accordance with the comprehensive assessment to meet the interests and the physical, mental, and psychosocial well-being for 2 of 21 residents (Resident #8 and Resident #19) reviewed for activities. The facility failed to ensure quarterly activity assessments were completed for Resident #8 and Resident #19 to provide activities to meet their interests. 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 interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. The facility did not ensure the Activity Director was qualified to serve as the director of the activities program. This failure could place residents at risk of not receiving a program of activities that meets their assessed activity needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 1 of 1 licensed staff (RN O) reviewed for nursing competencies. The facility failed to ensure RN O was competent in providing tracheostomy (small surgical opening that is made through the front of the neck into the windpipe, or trachea) care to Resident #19 when she did not check Resident #19's oxygen saturation or lung sounds. This failure could potentially affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills and competencies to provide safe care and minimize infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed provide pharmaceutical services, which included procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals, to meet the needs of each resident for 1 of 1 resident (Resident #38) reviewed for pharmacy services. The facility did not ensure RN E administered Resident #38's Novolog (insulin aspart) FlexTouch (insulin medication) according to the manufacturer's instructions. This failure could place the resident at risk of medical complications and not receiving the therapeutic effects of their medications.

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 safety in the facility's only kitchen. The facility did not ensure: 1. 6 sheet pans were free from encrusted black colored grease buildup coating the outside and the inside of the cooking surface. 2. the steam pans and plate domes were stacked with water pooled in between them. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for 2 of 5 shower rooms reviewed. (Hall 200 and Hall 300) The facility failed to ensure Hall 200 and Hall 300 shower rooms were free from missing or cracked tiles, and slime-like green, brown, and black material on the grout. These failures could place the residents at risk for a diminished quality of life and a diminished clean well-kept environment.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and the PASRR evaluation report into a resident's assessment, care planning, and transitions of care for one out of one resident (Resident #3) reviewed for PASRR. The facility failed to submit the NFSS forms timely for Resident #3 to the Texas Medicaid and Healthcare Partnership (TMHP) Long Term Care Portal. These failures could place residents identified at a Level II for PASRR Evaluation at risk for their specialized services not being provided in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry our activities of daily living receives necessary services to maintain grooming and personal hygiene were provided for 1 of 3 residents reviewed for ADLs (Residents #1). The facility failed to ensure Resident #1 received his baths. This failure could place resident at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings Included: Record review of Resident #1's face sheet, dated 11/29/23, indicated Resident #1 was a [AGE] year-old male, admitted to the facility on [DATE], with a diagnosis of respiratory failure (difficulty with breathing, type 2 diabetes (blood sugar disorder) and congestive heart failure (the heart does not pump blood like it should). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment was free of accidents and hazards for 1 of 4 shower rooms reviewed (Hall 300). The facility failed to ensure the shower chair in the Hall 300 shower room was not torn/ripped. The facility failed to ensure Hall 300 shower room was free from hazardous liquid. This failure could place residents at risk for injuries and falls. Findings Included: During an observation on 11/28/23 at 11:20 a.m., revealed the hall 300 shower room door was opened and unlocked with several opened bottles of shampoo sitting on the floor. During an observation and interview on 11/28/23 at 11:25 a.m., RN K said the shampoo bottles should not be left in the shower room unattended. RN K removed the shampoo bottles and said a confused resident could have drunk the shampoo because the shower room door did not lock. [...]

Inspectors wroteBased on interview, and record review, the facility failed to assist residents in obtaining routine and emergency dental services to meet the needs of 1 of 2 (Resident #1) residents reviewed for dental services. The facility failed to ensure Resident #1 received dental services when he had pain and a broken tooth. These failures could place residents at risk of not receiving needed dental care and a decreased quality of life.

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 2 of 62 residents (Resident #6 and Resident #4) reviewed for infection control. 1. The facility failed to ensure CNA M's mask was properly worn and sealed to face while providing patient care to Resident #6. 2. The facility failed to ensure CNA C performed hand hygiene and changed her gloves while providing incontinent care to Resident #4.