The Enclave

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 1 treatment carts (TC #1) reviewed for medication storage. The facility failed to ensure the treatment cart was locked. This failure could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents were free from abuse for 1 of 4 residents (Resident #1) reviewed for freedom from abuse. Resident #1 was kissed and touched by CNA A and it was recorded on the camera in her room. This failure could place residents at risk of abuse, neglect, and exploitation.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 4 residents (Resident #1) reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report to HHSC that Resident #1 was kissed and touched by CNA A. This failure could place residents at risk of unidentified and on-going abuse, neglect, and exploitation.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide assessments that accurately reflect the resident's status for three (Residents #41, #55 and #34) of 32 residents reviewed for MDS assessment accuracy. 1. Resident #41's MDS assessment did not accurately reflect she had an indwelling urinary catheter. 2. Resident #55's admission MDS assessment did not accurately reflect she had an indwelling urinary catheter. 3. Resident #34's MDS assessment did not accurately reflect she took an opioid medication. This deficient practice affects residents with MDS assessments and could result in missed or inappropriate care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at S483.10(c)(2) and S483.10(c)(3), 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 three ( Residents #17, #41 and #119) of 32 residents reviewed for comprehensive care plans. The facility failed to provide Resident #17 a call bell instead of a call light which was reflected in his comprehensive person-centered care plan. 2. The facility failed to reflect Resident #41 had an indwelling urinary catheter in her comprehensive person-centered care plan. 3. [...]

Inspectors wroteBased on observations, interviews, 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 3 (Resident #18, #150, and #1) of 7 residents reviewed for pharmacy services. 1. The facility failed to re-order on time Resident #18's Janumet 50-500 mg medication for diabetes. 2. The facility failed to re-order on time Resident #150's Carboxymethlcellulose sodium 0.5% eye drops for dry eyes. 3. The facility to ensure Resident #1's insulin Lispro KwikPen for diabetes had open date of [DATE], stored inside the 200-unit C-hall nursing cart was not expired. This failure could place residents at risk of not receiving appropriate therapeutic effects of medication.

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 for 1 of 1 kitchen. The facility failed to ensure: 1. Dietary Aide B failed to wear beard restraints while working in the kitchen.2. Dietary Aide A did not properly wear hair restraints in a way that covered all their hair.3. The facility failed to store wet dishes to allow for air-drying.4. The facility failed to ensure all prepared items in the walk-in refrigerator were labeled and dated with the use by date. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observation, 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 disease and infection for 3 of 5 residents (Residents #9, Resident #17 and Resident #105) reviewed for infection control. 1. The facility failed to ensure to utilize proper PPE for direct care of a resident with EBP precautions in place while performing Resident #9's suppository administration. 2. CNA E and CNA J did not clean Resident #17's anal area and rectum and left on his soiled socks when they performed incontinent care.3. LVN-Q measured Resident #105's blood pressure without cleaning the blood pressure cuff. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two (Resident #17 and Resident #108) of 32 residents observed for dignity and respect. 1. CNA E and J left Resident #17's anti-slip socks which were lying on a urine-soaked sheet on his feet after incontinent care. 2. LVN, I did not knock on Resident #108's door prior to entering his room to administer G-tube medications. These deficient practices could affect residents who require assistance with ADL's and could result in loss of dignity and decreased self-esteem.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or residents for one resident (Resident #17) of 32 residents observed for accommodation of needs. Resident #17's call light was located approximately 3 feet from the resident and wrapped around his wheelchair arm rest. This deficient practice could affect residents who require assistance with ADL's and could result in loss of getting needs met.

Inspectors wroteThe facility failed to ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; a resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one resident (#41) out of .three residents reviewed for indwelling urinary catheters. The facility failed to have a diagnosis or physicians order for August 2025 for Resident #41's indwelling urinary catheter. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care was provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for one (Resident #174) of six Residents who were reviewed for respiratory care. Resident #174's tubing and mask which were attached to a nebulizer for the resident's breathing treatment were not covered in a plastic bag when not in use. This deficient practice could place residents at risk of respiratory distress, infections, pneumonia and an overall decline in their physical condition.

Inspectors wroteBased on observations, interviews, 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 7.41% based on 2 errors out of 27 opportunities, which involved one (Residents #150) of seven residents reviewed for medication errors. a. LVNO did not administer Resident #150's Carboxymethylcellulose Sodium Ophthalmic Solution 0.5 % to both his eyes for dry eyes because the medication was not available on 08/25/2025 at 4:39 p.m. b. LVNO administered Resident #150's Timolol maleate 0.5 % eye drop for glaucoma on 08/25/2025 at 4:39 p.m., but the order and schedule was Administer Timolol maleate 0.5 % eye drop for glaucoma every 12 hours to Resident #150 at 8:00 am and 8:00 pm. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 (treatment cart) of 5 nursing carts and 1 resident (Resident #34) of 32 residents reviewed for storage, in that: 1. The facility failed to ensure the treatment cart was locked when left unattended. 2. The facility failed to notice and remove a jar of medicated chest rub from Resident #34's nightstand. This failure could place residents at risk of misappropriation of medications and not receiving therapeutic benefits of medications.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to post the following information on a daily basis for one of one facility. The facility failed to post daily staffing and census requirements for 5 days. This deficient practice affects, residents, visitors and staff and could result in a misconception of staff availability for care.

Inspectors wroteBased on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 2 residents (Resident #70) reviewed for MDS transmission. Resident #70's discharge MDS assessment was not transmitted within 14 days of completion. This deficient practice placed residents at risk of not having assessments submitted in a timely manner as required.

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 4 residents (Resident #2) reviewed for pharmacy services. LVN A did not administer Resident #2's Famotidine (Pepcid) 10 mg oral one tablet a day for indigestion on 07/20/2025 because she could not find the medication in the medication cart where it was stored. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 4 of 5 residents (Resident #1, #2, #4, and #5) reviewed for accuracy of records. 1. The facility failed to ensure Resident #1's bath or shower was documented as given or as refused 9 times in April and May 2025. 2. The facility failed to ensure Resident #2's bath or shower was documented as given or as refused 6 times in April and May 2025. 3. The facility failed to ensure Resident #4's bath or shower was documented as given or as refused 11 times in April and May 2025. 4. The facility failed to ensure Resident #5's bath or shower was documented as given or as refused 8 times in April and May 2025. These failures could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, in that: 1. The CDM wore a hair restraint that did not cover all his hair. 2. In the freezer, there was frozen raw beef stored over fully cooked frozen pies. 3. In the walk-in cooler, there were: a. Uncovered foods of 3 trays of pie desserts, 2 trays of bowels of fruits, and 1 tray of plates of salad. b. Cheese that was inappropriately stored. c. The CDM revealed he did not label prepare foods with a discard date. 4. In the dish room, the temperature log of the dishwashing machine had the wrong temperature 5. For 06/28/24 lunch, fortified shakes and yogurt temperatures were taken by touching the thermometer outside of the food product and not inside of the food product. 6. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure each resident was free of any significant medication errors for 1 of 8 residents (Resident #35) reviewed for medications. The facility failed to provide Resident #35 with Diltiazem HCl Oral Tablet 30 MG (treats high blood pressure) as Diltiazem HCl Oral Tablet 30 MG Give 1 tablet by mouth three times a day for heart Monitor BP hold medication if SBP <110 or HR <60 bpm notify MD This deficient practice could result in a risk to the residents' health and complications which can lead to symptoms of heart failure.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 4 (Resident #29, #228, #2, #100 and #4) of 23 residents reviewed, in that: 1. Resident #29's personal refrigerator was dirty with old and brown colored food debris. 2. Resident #228's personal refrigerator had undated soup with rice. 3. Resident #2's personal refrigerator's door was broken and not closed perfectly, and there was one opened food item unlabeled and undated in the refrigerator. 4. Resident #100's personal refrigerator had undated fried chicken. 5. Resident #4's personal refrigerator had expired foods in it.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 2 of 23 Residents (Resident #4 and Resident #49) who were observed for call light placement. Nursing staff failed to ensure the call light was within reach for Resident #4 and Resident #38. This deficient practice could affect any resident and keep them from calling for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 10 Residents (Resident #38, and Resident #116) whose MDS records were reviewed for accuracy. 1. The facility failed to ensure Resident #38's Quarterly MDS assessment dated [DATE] documented Resident #38 received a therapeutic diet while a resident at the facility. 2. The facility failed to ensure Resident #116's discharge MDS assessment, dated 04/29/2024, accurately reflected the resident's discharge status. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on interview and record review, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 2 residents (Residents #13) reviewed for PASRR screening, in that: Resident #13's PASRR Level 1 assessment did not accurately capture the resident's diagnosis of mental illness. These failures could put residents with inaccurate PASRR Level 1 Evaluations 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 a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal and oral hygiene for 1 of 7 Residents (Resident 51) whose records were reviewed for ADL care. Nursing staff failed to wash his face, apply cream to his face, to clean his lips and cut his finger nails for 1 of 4 observations. These deficient practices could affect any dependent resident and could lead to the resident's decline in their physical health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was fed by enteral means received the appropriate treatment and services to prevent complications from enteral feeding for 1 (Resident #103) of 2 residents reviewed for enteral feeds. The facility failed to ensure Resident #103's water with enteral feed was properly administered at the correct rate of infusion. This failure could place residents at risk of not receiving the proper hydration requirements prescribed by the physician.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that Residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #66) of 3 residents reviewed for respiratory care. The facility failed to ensure Resident #66's nebulizer mask was properly stored and dated. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure If a bed or side rail was used, the facility must ensure resident assessment of the resident for risk of entrapment from bed rails for 2 of 7 Residents (Resident #4 and Resident #33) whose records were reviewed for side rail use. Nursing staff did not assess Resident #4 and Resident #33 periodically per facility policy since initial assessment upon admission to the facility. This deficient practice could affect any resident using a side rail and could contribute to avoidable incidents of entrapment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly for 1 of 5 residents (Resident #52) reviewed for medication storage, in that: The facility failed to ensure medications were not left on Resident #52's bed side table. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications as ordered.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meals (lunch meal on 06/25/2024) reviewed for menus in that: 1. The facility failed to follow the menu for residents on regular and modified diets for the lunch meal on 06/25/2024. This failure could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accommodate residents' food preferences and allergies for 2 of 8 (Residents #35 and #79) residents reviewed for food preferences and allergies, in that: 1. The facility failed to provide Resident #79 with a protein, when he had a listed dislike for the protein served for 06/25/24 lunch. 2. The facility failed to ensure Resident #35 did not receive fish for 06/28/24 lunch, which was listed as a food allergy in her medical record. These failures could cause an allergic reaction, a decrease in resident choices, a diminished interest in meals, placing them at risk for contributing to poor intake and/or weight loss. 1. Record review of Resident #79's admission record, dated 06/25/2024, reflected the resident was admitted to the facility on [DATE] with diagnoses to include: [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 2 Residents (Residents #103 and Resident #51) of 23 residents reviewed for infection control. 1. LVN P entered Resident #103's room, who was on EBP, on 06/26/2024 at 04:10 p.m., and failed to put on a gown when the nurse performed wound treatment for Resident 103. 2. ADON entered Resident #51's room, who was on EBP and failed to wash or sanitize her hands, put on a gown when checking to ensure the G-Tube was connected when the G-Tube pump shut off. These deficient practices affect residents who require direct care and could place residents at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 6 residents reviewed for accidents. NA E failed to use an assistive device used for lifting and transfers on 4/30/24 when transferring Resident #1, resulting in Resident #1 experiencing pain to her Right ankle and requiring an x-ray. This failure could place residents at risk of injuries and a decline in quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #1) reviewed for accidents, in that: 1. The facility failed to provide adequate supervision of Resident #1 on 02/25/2024 resulting in the resident being found outside of the facility on 02/25/2024 at 4:51 PM. 2. The facility failed to provide adequate supervision of Resident #1 on 04/28/2024 resulting in the resident being found outside of the facility on 04/28/2024 at 9:31 PM. An IJ was identified on 05/02/204. The IJ template was provided to the facility on [DATE] at 4:15 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide routine and emergency drugs and biologicals to its residents for 1 of 5 residents (Resident #4) reviewed for medications, in that: The facility failed to provide Resident #4 with Amiodarone (an antiarrhythmic used to treat heart rhythm problems) on 04/14/2024 resulting in one dose missed; Alprazolam (a sedative used to treat anxiety and panic disorder) on 04/14/2024 resulting in one dose missed; and Loratadine (an antihistamine used to treat allergy symptoms and hives) on 04/14/2024 resulting in one dose missed; Gemtesa (a medication used to treat an overactive bladder) on 04/13/2024, 04/14/2024, and 04/15/2024 resulting in three doses missed; and Latanoprost (a medication used to treat glaucoma) on 04/13/2024, 04/14/2024, and 04/15/2024 resulting in three doses missed. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to treat residents with dignity and respect for 3 of 3 residents (Residents #1, #2 and #3) observed in that: LVN A addressed Residents #1, #2 and #3 as, honey, and, sweetheart. This failure could affect residents' by failing to protect and promote the residents' rights causing them to feel uncomfortable and disrespected.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving neglect were reported immediately, but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 1 resident (Resident #1) reviewed for reportable incidents, in that: 1. Facility staff failed to report to the Administrator Resident #1's elopements on 02/25/2024 and 04/28/2024. 2. The facility failed to ensure a report was made to the State Survey Agency regarding Resident #1 being found outside of the facility on 02/25/2024 at 4:51 PM. 2. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was free of any significant medication errors for 1 of 5 residents (Resident #4) reviewed for medications. -The facility failed to provide Resident #4 with Amiodarone (an antiarrhythmic used to treat heart rhythm problems), Alprazolam (a sedative used to treat anxiety and panic disorder), and Loratadine (an antihistamine used to treat allergy symptoms and hives) until -The facility failed to provide Resident #4 with Gemtesa (a medication used to treat an overactive bladder) and Latanoprost (a medication used to treat glaucoma) until This deficient practice could result in a risk to the residents' health and complications which can lead to stroke, heart failure, sudden cardiac death.

Inspectors wroteBased on observation, interviews and record review, the facility failed to establish and maintain an infection 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 3 residents (Resident #14) observed for infection control, in that: 1. Prior to beginning wound care for Resident #14, LVN A left the prepared wound care supplies unattended in the resident's room 2. During wound care for Resident #14, LVN A wiped from the top of the resident's wound and through the wound. This failure could affect residents who receive wound care and could result in cross contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 2 of 5 residents (Resident #2 and Resident #5) reviewed for drug administration in that: The facility did not ensure Resident #2 and Resident #5 received their 8:00 a.m. medications on time. This deficient practice could affect residents and place them at risk for not receiving a therapeutic effect.

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 5 residents (Resident #5 and Resident #4) reviewed for infection control in that: 1. LVN A did not sanitize the blood pressure cuff prior to using the wrist blood pressure cuff on Resident #5. 2. Nurse Aide in Training B did not perform hand hygiene after cleansing Resident #4's perineal area and prior to touching Resident #4. This deficient practice could affect residents and place them at risk for infection.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 4 resident reviewed . (Resident #14, Resident #88, and Resident #226) The facility failed to develop a care plan for hypnotic medication use, for the medical management of dementia with behavioral disturbance, insomnia, and hypertension for Resident #14. The facility failed to develop a care plan for anti-depressant medication use, for the medical management of hypertension, and type 2 diabetes mellitus for Resident #88. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure each resident's drug regimen was free from unnecessary drugs, An unnecessary drug is any drug used without adequate monitoring, for 4 (Resident #88, Resident #226, Resident # 14 and Resident #13) of 4 Residents reviewed for psychotropic medications. The facility failed to have an adequate indication of use, and monitoring for efficacy and adverse consequences for Resident #88 for the use of trazodone HCl 25mg, Venlafaxine HCl ER 15mg, and Xanax 0.5mg. Resident #226, and Resident #14 for the use of psychotropic medications. The facility failed to have an indication of use, and monitoring for efficacy and adverse consequences for Resident #226 for the use of Aripiprazole 10mg, Brexpiprazole 2mg, Lorazepam 1mg, Seroquel 100mg, and trazodone HCl 100mg. [...]

Inspectors wroteBased on observations, interviews and record review the facility failed to store, distribute, and serve food in accordance with professional standards for food safety in the facilities only kitchen. The facility failed to ensure food items past their expiration date were discarded. This failure could place residents at risk for food-borne illness.

Inspectors wroteBased on record review and interview, this facility with more than 120 beds, failed to employ a qualified social worker on a full-time basis for one (Social Worker) of one Qualified Social Worker reviewed for Social Services. The facility was licensed for 142 and failed to ensure they employed a full-time, qualified social worker since 03/02/23. This deficient practice could result in the residents' social service needs not being met, which could result in a decline in their mental and psychosocial well-being.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure the residents received proper treatment to maintain hearing abilities in making appointments for three (Residents #17, #50 and #50) of nine residents reviewed for hearing checkups. The facility failed to follow their own policy with scheduling appointments and did not ensure hearing checkups were completed for Residents #17, #50 and #60. This failure could affect all the residents by placing them at risk of not having their healthcare needs met which could lead to a decline in their hearing and psycho-social wellbeing with being able to communicate effectively.