The Village at Incarnate Word

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 facility. The facility failed to ensure food safety was maintained during a potluck event hosted by Volunteer D on 12/09/2025. This failure could place residents who participated in potluck events hosted by family and visitors at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to have 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. The facility failed to provide a policy regarding use and storage of foods brought to residents by family and other visitors and failed to explain safe food handling practices to Volunteer D, who brought hot food items to the facility on [DATE]. This deficient practice could place residents at risk for foodborne illness.

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 disease and infection for 1 of 5 residents (Resident #4) reviewed for infection control, in that:The facility failed to ensure enhanced barrier precautions was used by the staff for Resident #4 who had a wound. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to dispose of garbage and refuse properly for one of two refuse containers (the recycling bin) and one of one grease containers on the loading dock. 1. The facility failed to ensure the waste in the recycling bin was placed inside the bin to allow the top lid to close. 2. The facility failed to ensure the grease container was free of grease, grime and food particles outside the container and on the ground in front of the container. These deficient practices could place residents at risk for illness from exposure to germs and diseases carried by vermin and rodents.

Inspectors wroteBased on observations , interviews, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 1 of 9 residents (Resident #1) reviewed for accidents and supervision. The facility failed to supervise Resident #1 whose injury of left eye bruising during a bath using a Mechanical lift. CNA A was using a mechanical lift by herself on 12/2/2025 to transfer Resident #1. The non-compliance began on 12/6/2024 and ended on 12/23/2024. The facility had corrected the non-compliance before the survey began on 05/14/2025. This deficient practice could place residents at risk that required a Mechanical lift at risk of harm, serious injury, or death.

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 reviewed in that: 1. A fire extinguisher inspector was not wearing a beard guard or full hair net in the kitchen during food preparation. 2. Pudding cups in Refrigerator #1 were neither labeled nor dated. 3. Chili in Refrigerator #2 was neither labeled nor dated. 4. Pie crusts in Freezer #1 were unsealed. These deficient practices could result in foodborne illness for those who consume snacks and meals prepared in the kitchen.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 18 residents (Resident #10) reviewed for care plans. The facility failed to ensure Resident #10's care plan dated 08/20/2024 reflected the resident's current diet texture order which had been updated/changed 08/30/2024. This failure could place residents at risk of not receiving appropriate care to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 (Rooms #13 and room [ROOM NUMBER]) residents' refrigerators reviewed in that: The personal refrigerators in Rooms #13 and #14 contained food items which were unlabeled and undated. This deficient practice could place residents at risk of foodborne illness due to consuming foods which are spoiled.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable and homelike environment for one of four resident hallways (Red Hall) reviewed, in that: The water temperature in the Red-Hall (Rooms 18, 20, 21, and 27) exceeded 110 degrees Fahrenheit. This deficient practice cause scalding or other physical injuries to residents and staff.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 2 newly admitted residents (Resident #103) reviewed for baseline care plans in that: Resident #103's baseline care plan did not include her use of oxygen when needed for shortness of breath This deficient practice could result in newly admitted residents receiving improper care.

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed that it was appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record, and indicate the duration for the PRN order for 1 of 3 residents (Resident #49) reviewed for pharmacy services . The facility failed to ensure Resident # 49 had a stop date for PRN Lorazepam 0.5 mg (a medicine used to treat the symptoms of anxiety) This failure could affect residents who received antipsychotic/psychoactive medications and could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that are accurately documented for 1 (Resident #29) of 18 residents reviewed, in that: Resident #29's prescription for Tylenol included incorrect excessive dosage parameters. This deficient practice could result in liver failure due to residents receiving excessive dosages of acetaminophen.

Inspectors wroteBased on observation, 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 and transmission of communicable diseases and infections for 1 of 2 residents (Resident #37) observed for wound care in that: LVN-A failed to sanitize her hands between glove changes while performing wound care and failed to wash or sanitize her hands or change her gloves after touching the bedside table while providing wound care to Resident #37. These failures could result in cross contamination of germs and could result in an infection or 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 2 kitchens. The facility failed to ensure the main kitchen's 1 of 2 refrigerators a wrapped partially used wrapped thawed ground turkey package was stored properly on the bottom shelf of the refrigerator and had been discarded with in 3 days of opening. The facility failed to ensure in the main kitchen pantry 1 partially used box of cream of wheat was properly sealed and dated with open date. These failures could place residents who receive meals from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for one resident (#6) of three residents reviewed for oxygen therapy, in that: Resident #6's oxygen was set to 2.5 L/min instead of 2L/min as ordered by the physician. This deficient practice could affect residents who receive oxygen therapy and could result in respiratory distress.

Inspectors wroteThe facility failed to provide food prepared in a form designed to meet individual needs for 2 (Resident #6 and #25) of 2 residents observed for pureed diets in that: Resident #6 and #25's pureed food was not at the right consistency. This deficient practice could affect residents on pureed diets and could result in choking.

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, or 2 residents (#11 and #32) of 6 residents observed for medication pass in that: CMA B failed to sanitize the blood pressure cuff between Resident #11 and #32 to prevent cross contamination. This deficient practice had the potential to affect residents in the facility by placing them at risk of contracting, spreading and/or exposing them to pathogens that could lead to the spread of communicable diseases.