The Palms Nursing & Rehabilitation

Inspectors wroteBased on 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 for 1 of 4 residents (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure Resident #1's Tylenol #4 300/60mg was received and counted appropriately by LVN A, when hospice delivered medication the resident to the facility. This failure could place residents at risk of pain.

Inspectors wroteBased on interviews, and record review the facility failed to develop and implement a person-centered comprehensive care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for one (Resident #1) of six residents reviewed. The facility did not develop a measurable and individualized care plan to address Resident #1's falls. This failure could place residents at risk for unmet medical, nursing, mental, and psychosocial needs and preferences. Record review of face sheet dated 12/18/2025 revealed Resident #1 was last admitted on [DATE]. Resident #1's Face sheet also revealed admission and Primary Diagnosis as Unspecified Dementia (a decline in mental ability severe enough to interfere with daily life, affecting memory, thinking, language, judgement and behavior). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 1 of 5 residents (Resident #4) reviewed for abuse, neglect, and exploitation. The facility failed to protect Resident #4's right to be free from verbal abuse when CNA-C made an insulting and ridiculing comment toward Resident #4 on 10/25/2025. This failure could place residents at risk for psychological harm or injury.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented within a timely manner for each resident, consistent with resident rights, to include measurable objectives and timeframes to meet resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 5 residents (Resident #3) reviewed for care plans. The facility failed to develop or implement Resident #3's comprehensive care plan when, after searching for over 3 hours, they were unable to find Resident #3's comprehensive care plan in her chart, on the electronic medical system, or in medical records. This failure could place residents at risk of receiving inadequate care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments, and the change of condition assessments to reflect the current conditions for 2 of 5 residents (Resident #1 and Resident #2) whose care plans were reviewed for timing and revision. The facility failed to ensure Resident #1's care plan was revised after a significant change to accurately reflect current diagnoses and needs. The facility failed to ensure Resident #2's care plan had been reviewed or revised since 2024. These failures could place residents at risk of receiving inadequate, individualized care and services.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #36, Resident #11, Resident #88, Resident #58) of 18 residents reviewed for care plans. The facility failed to develop and implement a comprehensive care plan for Resident #36, Resident #11, Resident #88, and Resident #58. This deficient practice could place residents at risk of not receiving services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for two of six residents (Resident #66 and Resident #93) reviewed for medication errors in that: 1) The facility failed to ensure Resident #66 was administered glargine insulin appropriately within parameters on 08/19/25 and 08/25/25. 2) The facility failed to ensure Resident #93 was administered glargine insulin appropriately by administering expired insulin on 09/16/25 and 09/17/25. These failures could place residents who receive insulin at an increased risk for complications such as hypoglycemia (low blood sugar), hyperglycemia (high blood sugar) and potential hospitalization.

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 and 1 of 1 nutrition rooms (first floor and second floor nutrition room) reviewed for sanitation. The facility failed to ensure items in the refrigerators and freezers were labeled and dated. The facility failed to ensure items stored in the dry storge room were correctly dated and labeled. The facility failed to ensure refilled cereal in cereal dispensers were dated and label with correct date. The facility failed to ensure gloves were used at all times while making preparing uncooked foods. The facility failed to ensure applesauce and pudding sitting out in room temperature were labeled with current date and time. These failures could place residents at risk of foodborne illnesses.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of infection, for 2 of 5 Residents (Resident #40 and Resident #63) that were reviewed for infection control in that: 1. The facility failed to ensure the wound dressing on Resident #40 was dated and initialed. 2. The facility failed to ensure CNA I performed proper perineal care (incontinent care) with Foley catheter for Resident #63. These deficient practices could place residents in the facility at risk for infections, healthcare associated cross contamination, and the spread of infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure each resident had a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 (Resident #5) of 5 residents reviewed for resident rights. The facility failed to provide Resident #5 with choices concerning her caregivers for personal care. LVN D did not leave the room when Resident #5 asked her multiple times to step out on 08/23/25. LVN D did not treat Resident #5 with respect and dignity on 09/05/25. This failure could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from abuse, neglect, misappropriations of resident property, and exploitation for 1 (Resident #5) of 5 residents reviewed for abuse. LVN D was verbally abusive to Resident #5 on two occasions on 08/24/25 and 09/05/25. This failure could place residents at risk for physical, mental, and/or psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to implement its written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 (Resident #5) of 6 residents reviewed for abuse and neglect. The DON failed to follow the facility's policy to report an allegation of verbal abuse made by Resident #5 on or about 08/24/25 to the administrator, the ombudsman, or to the Texas Health and Human Services Commission (HHSC). This failure could place the residents in the facility at risk for physical, mental, and/or psychosocial harm and lack of timely reporting of incidents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown sources were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency in accordance with State law through established procedures for 1 (Resident #5) of 6 residents reviewed for reporting. [...]

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the Pre-admission Screening and Resident Review (PASRR) program to the maximum extent practicable to avoid duplicative testing and effort for 1 of 3 residents reviewed for PASRR. (Resident #8). The facility failed to refer Resident #8 for PASRR Level II assessment when the facility had coded mental illness on his PASRR Level I assessment. This failure could place residents at risk of not receiving specialized services that would enhance their highest level of functioning.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene, for one (Resident #86) of 3 residents reviewed for activities of daily living. The facility failed to provide Resident #86 with fingernail grooming. This failure could result in decrease in resident self-esteem, embarrassment, and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, physicians orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #47) residents reviewed for respiratory care. The facility failed to ensure Resident #47's oxygen tubing was changed and documented every night shift on Sunday as ordered. This failure could place residents at an increased risk of infection leading to a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 4 medication carts (2300/2400 Cart) reviewed for storage. The facility failed to ensure the medication cart for halls 2300/2400 was free from expired insulin pens. The failure could place residents in the facility at risk of receiving expired medications from staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 3 residents personal refrigerators reviewed for food safety (Resident #114) in that: Resident #114's personal refrigerator located in her room was observed to have 2 slices of pie that were not dated or labeled. This failure could place residents at risk for food-borne illnesses.

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 of 6 residents (Resident #66) reviewed for accuracy and completeness of clinical records. The facility failed to accurately document the glucagon injection (hormone produced by the pancreas that raises blood sugar levels by signaling the liver to release stored glucose) Resident #66 received at approximately 7:45 AM on 07/08/25 in the MAR. This failure could result in residents' records not accurately reflecting the administration of medications and could result in further errors due to inappropriately administering medications twice.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public for 2 of 2 resident's bathroom sink (Resident # 43 and #88) and 2 of 5 resident rooms (Resident #76 and Resident #114) reviewed for the environment in that: The bathroom sinks in resident #43's and Resident #88's room were clogged. Resident #76's wall pad and floor mats were torn. Resident #76's nightstand was broken. Resident #114's bathroom sink cabinet door was missing. Resident #114's trim wall trim inside her bedroom was broken off. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortableA record review of Resident #43's Face Sheet 09/16/25 revealed a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed for pests. The facility failed to maintain an effective pest control program for gnats flying in the dish room of the kitchen, and there was a foul odor in the dish room. These failures could put residents who consumed food from the kitchen at risk for infection and/or food contamination.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to be free from abuse for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from verbal abuse when CNA-A yelled at and ridiculed Resident #1 on 10/16/2025 as he was requesting assistance. These failures could place residents at risk of physical, mental and emotional decline, psychosocial harm, as well as result in isolation and withdrawal.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, and/or mistreatment were reported immediately, but not later than 2 hours after the allegation was made if the allegation involved abuse or resulted in serious bodily injury, or no later than 24 hours if the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (including the State) in accordance with state law for 1 of 5 residents (Resident #2) reviewed for abuse and neglect. The facility failed to ensure all alleged possible violations or allegations involving abuse for Resident #2 were reported to the proper entities immediately or as required by law on 10/08/2025. [...]

Inspectors wroteBased on interview and record review the facility failed in response to allegations of abuse, neglect, exploitation, or mistreatment have evidence that all alleged violations were thoroughly investigated and prevented further potential abuse, neglect, exploitation or mistreatment while the investigation was in progress for 1 (Resident #2) of 5 residents reviewed for abuse, neglect, and/or misappropriation. The facility failed to do a thorough investigation to include having the CNA and/or charge nurse perform a thorough assessment of the situation and the environment of the residents identified in the abuse allegation the night of 10/08/2025. The facility also failed to have the charge nurse assess the residents identified in the allegation the night of 10/08/2025. [...]

Inspectors wroteBased on interviews and record review, the facility failed to report immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or 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 by one staff member (the SW) of five staff members reviewed for reporting of abuse allegations. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to ensure residents were free from accident hazards and received adequate supervision and assistance devices to prevent accidents for one (Resident #2) of three residents reviewed for accidents. 1. The facility failed to ensure Resident #2 did not fall out of his bed on 07/08/25 due to CNA C performing incontinent care alone instead of with a second person. This failure could place residents at risk for physical, mental, and psychosocial harm.

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 5 of 5 residents (Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7) reviewed for accuracy of records. The facility failed to ensure Resident #1, Resident #2, Resident #5, Resident #6, and Resident #7 had documented Quarterly Elopement Assessments since January 2025. This failure could place residents at risk for improper care due to inaccurate or incomplete assessments and records.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were treated in a respectful manner that maintained or enhanced each resident's dignity for 1 (Resident #3) of 6 residents reviewed for dignity. The facility failed to treat Resident #3 with dignity and respect during a post-fall assessment by RN D in Resident #3's room on 05/16/25. RN D asked Resident #3 in a stern tone What is wrong with you and Do you want to break something while Resident #3 was still on the floor post-fall. This failure could place residents who require assistance from nurses at risk of feeling disrespected.

Inspectors wroteBased on interview and record review the facility failed to have evidence that all alleged violations were thoroughly investigated and measures were taken to prevent further potential abuse, neglect, exploitation or mistreatment in accordance with State law, and if the alleged violation was verified appropriate, corrective action must have been taken for 1 (Resident #1) of 5 residents reviewed for abuse, neglect, and/or misappropriation. The facility failed to do a thorough investigation to include interviewing the victim (Resident #1) in the incident, the victim ' s RP, as well as other residents which may have been involved in the incident. This failure placed residents at risk of not having their allegations investigated thoroughly or timely.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 (Resident #3) of 6 residents reviewed for quality of care. The facility failed to enforce the post-fall assessment policy leading to Resident #3 being moved after a fall prior to checking her vital signs and neurological status on 05/21/25. The failure could affect residents currently residing in the facility, resulting in not receiving needed care to maintain optimal health and placing them at risk for injury or deterioration in their condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to ensure LVN-A's medication cart on hall 300 contained an accurate count and record for Resident #1's Clonazepam 0.125 MG (a medication used to treat seizure disorders and panic disorder). This failure could place residents at risk for drug diversion and/or a delay in medication administration, as well as risk of not having allegations investigated throoughly or timely.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the safe and orderly discharge for one (Resident #1) of four residents. Based on interviews and record review, the facility failed to ensure the safe and orderly discharge for one (Resident #1) of four residents. The facility (Facility A) failed to plan a coordinated discharge and returned Resident #1 back to the discharging facility (Facility B) on the same day. This failure placed Resident #1 in the hospital due to the original discharging facility not accepting the resident.

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 one of four residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure CNA A used a gait belt to transfer Resident #1 from the bed to the wheelchair . This failure could place residents at risk for falls, injuries and a decline in health.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for one (R#3) of 4 residents reviewed for injuries of unknown origin. The facility failed to ensure a resident remained free from an injury of unknown origin. Resident #3 suffered a dislocated shoulder and a later identified broken elbow . This failure could place residents at risk for further accidents and injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to develop and implement a person-centered comprehensive care plan for one (Resident #1) of four residents reviewed. The facility failed to care plan Resident #1's preferences to leave the building and the actions or long-term goals to meet the needs of the resident. This failure could place residents at risk for unmet medical, nursing, mental, and psychosocial needs and preferences.

Inspectors wroteBased on record review and interview the facility failed to perform preadmission screening for individuals with a mental disorder and individuals with intellectual disability prior to admission for 1 of 3 residents (Resident #39) reviewed for preadmission screenings. The facility failed to perform a PASRR for Resident #39 before or after she was admitted on [DATE] with readmission on [DATE]. This failure could place residents at risk of receiving inadequate care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the comprehensive care plans were reviewed and revised by the interdisciplinary team after each assessment, for 3 residents (Resident #8, Resident #34, and Resident #48) of 18 residents whose care plans were reviewed, in that: 1) Resident #8's comprehensive care plan was not reviewed or revised to include Resident #8's current code status of Full code, instead of Do Not Resuscitate. 2) Resident #34's comprehensive care plan was not reviewed or revised to discontinue Resident #34's use of insulin. 3) Resident #48's comprehensive care plan was not reviewed or revised to discontinue Resident #48's wounds or wound vac (medical device that helps wounds heal by applying negative pressure to the wound site). [...]

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 and 2 of 2 nutrition rooms (first floor and second floor nutrition room) reviewed for sanitation. The facility failed to maintain the dish room in a safe, sanitary condition. The facility failed to keep the dish room walls and floor clean. The facility failed to keep the ice machine clean and free of leaks. The facility failed to serve juices and milks in clean drinking glasses. The facility failed to keep the air intake filter above the stainless-steel refrigerator clean. The facility failed to keep hot dogs in the refrigerator tightly sealed. The facility failed to maintain 2 chest type freezers in good working order. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests in 1 of 1 kitchen reviewed for pests. The facility failed to maintain an effective pest control program for gnats flying in the dish room of the kitchen, and there was a foul odor in the dish room. The facility failed to ensure there was not a method for rodents to enter the kitchen due to a gaping hole in the baseboard. These failures could put residents who consumed food from the kitchen at risk for infection and/or food contamination.

Inspectors wroteBased on interviews and record reviews, the facility failed to send a copy of the notice of transfer or discharge, and the reasons for the transfer or discharge in writing to the resident, resident representative, or the Office of the State Long-Term Care Ombudsman for two (Residents #37 and #81) of three residents reviewed for transfer and discharge. The facility failed to send the notice of transfer or discharge in writing to Residents #37 and #81, their RP or the Ombudsman when Resident #37 transferred to emergency room on 8/13/24, and Resident #81 was transferred to the hospital on 6/28/2024. This failure could affect residents by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes.

Inspectors wroteBased on interviews and record reviews the facility failed to refer for a PASRR level II screening who had newly evident or possible serious mental disorder, intellectual disability, or a related condition for review upon a significant change in condition for 1 of 3 residents (Resident #37) reviewed for PASRR. The facility failed to refer Resident #37 for a PASRR level II review after resident received diagnoses of Anxiety, Bipolar with Severe Psychotic Features, Adjustment Disorder, Suicidal Ideations, Depression, Personality Disorder, Mood Disorder. This deficient practice could affect residents who received new mental illness diagnoses by not receiving additional evaluations and needed services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who entered the facility with a urinary catheter received appropriate treatment and services to prevent urinary tract infections for 1 (Resident #34) of 4 residents reviewed for urinary catheters in that: The facility failed to ensure that Resident #34 ' s urinary catheter drainage bag did not touch the floor. This failure could place residents who had a urinary catheter at risk for developing or worsening of a urinary tract infection. Findings Included: Record review of Resident #34 ' s face sheet revealed a [AGE] year-old female originally admitted on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure all drugs and biologicals were safely stored in 1 of 4 medication carts (300-hall cart) reviewed for storage of medications. -The facility failed to ensure disinfectant wipes on the 300-hall medication cart were kept in a separate compartment away from resident's medications. -The facility failed to ensure staff 's personal drink items were not stored in the 300-hall medication cart with resident's medications. This failure could affect residents receiving medications and put them at risk for cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 stainless-steel refrigerator, 2 of 2 chest type freezers (freezer A and freezer B), 1 of 1 refrigerator intake filter, 1 of 1 electrical box, and 1 sink drain reviewed for essential equipment in the kitchen. The facility failed to maintain sink drainage in the dish room of the kitchen, and there was a foul odor in the dish room. The facility failed to maintain an electrical box in the dish room of the kitchen. The facility failed to maintain the seals/gaskets on 2 chest type freezers. The facility failed to keep the air intake filter above the stainless-steel refrigerator clean. The facility failed to keep the ice machine clean and free of leaks. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 3 of 8 halls (Halls 200, 2200, and 2400) reviewed for environment. 1) The facility failed to keep a storage room containing mouthwash with alcohol on hall 2400 locked while not in use. 2) The facility failed to keep the shower room on hall 200 and hall 2200 locked while not in use. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be free from abuse for one (Resident #1) of fifteen residents reviewed for abuse. The facility failed to protect Resident #1 from being verbally abused by SA on April 29th 2024. The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began. This failure placed all residents at the facility at risk of severe psychosocial harm by being forced to interact with an employee that verbally abuses residents.

Inspectors wroteBased on record review and interview the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation for 1 of 5 residents (Resident #1) reviewed for neglect and abuse. The facility failed to report verbal abuse by the SA to local law enforcement in accordance with state law on 04/29/24 The non-compliance for Resident #1 was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 04/29/2024 and ended on 04/29/2024. The facility corrected the non-compliance before the investigation began. This failure could place residents at risk of continued victimization, abuse, humiliation, intimidation, fear, shame, agitation, and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to securely store all drugs and biologicals in locked compartments under proper temperature control, and permit only authorized personnel to have access to keys in that: An unknown nurse left Resident #2's discontinued medication in a clear bin, affixed to the ADON's office door, which left it easily accessible to all mobile residents and visitors. These deficient practices could affect residents with medications and could result in missing or misuse of drugs by unauthorized personnel.

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 disease and infection for one (Resident #3) of five residents reviewed for infection control, in that: 1. CNA A did not perform hand hygiene during Resident #3's perineal care. 2. CNA A did not perform under foreskin cleansing care of Resident #3's penile area. These failures could place residents at risk for contamination and infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided for the resident's immediate care and needs for 1 of 5 residents (Resident #3) reviewed for physician services. The facility failed to ensure there were orders for R#3's type 2 diabetes mellitus with hyperglycemia. On 12/22/23 at 3:55 PM an Immediate Jeopardy (IJ) was identified., while the IJ was removed on 12/23/23 at 6:30pm, the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could cause a delay in appropriate medical care and a worsening in symptoms, condition or illness up to and including death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to respect the resident's right to personal privacy during care, for one (R#1) of five residents reviewed for privacy issues, in that: CNA A did not provide privacy when providing R#1 with perineal care. This failure could place residents at risk for embarrassment, poor self-esteem, and unmet needs.

Inspectors wroteBased on observation, record review, and interview, 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 one (R# 1) of five residents reviewed for infection control and transmission-based precautions policies and practices, in that: CNA A did not perform hand hygiene after touching R#1's immediate environment, nor did she perform any glove changes or hand hygiene when cleaning from the R#1's perineal area to R#1's gluteal folds. These failures could place residents at risk for infection through cross contamination of pathogens.

Inspectors wroteDuring an observation, interview, and record review, the facility failed to ensure the water temperature was safe, clean, comfortable, and homelike for 1 out of 4 halls reviewed for water temperature. The facility did not provide water in the 200 hall shower that was between 100 and 110 degrees F This failure could place residents that resided on Hall 200 at risk for an unpleasant bathing experience, inadequate hygiene, burns, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet the resident's medical, nursing, mental, and psychosocial needs, for one Residents (R#88) of fourteen residents reviewed for care plans. The facility did not implement the comprehensive person-centered care plan set forth for Resident #88. This failure could place residents at risk for not being provided necessary care and services.

Inspectors wroteBased on interview and record review, the facility failed to ensure a qualified professional directed the activities program for the facility for one of 19 (Activity Director) employees reviewed for compliance. The current facility Activity Director was not a qualified therapeutic recreation specialist or an activities professional who met state licensure requirements. This failure could place residents at risk for reduced quality of life due to lack of activities that were individualized to match the skills, abilities, and interest/preferences of each resident.

Inspectors wroteBased on observation, record review, and interview, the facility failed to ensure each resident was free of accident hazards, on hall 2500, for one of three shower rooms observed for chemical accidental hazards. Facility failed to secure the shower room door and securely store chemicals to keep out of reach from any mobile cognitively impaired resident that resided on the second floor. These failures could place residents at risk for accidental poisonous hazards

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that one resident with an indwelling urinary catheter received appropriate treatment and services for one (Resident #3) of three residents reviewed for urinary catheters, in that: CNA A did not ensure Resident #3's indwelling catheter tubing, was allowed to flow freely via gravity drainage, as indicated in Resident #3's physician's orders. Resident #3's catheter bag was incorrectly positioned on top of the resident's bed, which situated above the resident's bladder for an undetermined amount of time, during the whole duration of perineal catheter cleaning. Back-flow of urine was observed during the catheter cleaning as well as when CNA A held indwelling catheter, in midair, above shoulder length, for three to five seconds. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to designate a person to serve as director of food and nutrition services who is a certified dietary manager 1 of 1 facility staff in that: The facility has been without a certified dietary manager since October 2020. This failure could result in the dietary needs of all residents served by the kitchen not being met.

Inspectors wroteBased on observation, record review, and interview, 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 one (CNA A) of three staff that were observed for infection control and transmission-based precautions policies and practices, in that: CNA A did not remove her contaminated gloves after touching multiple surfaces prior to commencement of perineal foley catheter cleansing, as well as maintained usage of same contaminated gloves during perineal catheter foley care and did not perform hand hygiene during care procedure. These failures could place residents at risk for infection through cross contamination of pathogens.