Town and Country Nursing and Rehabilitation Center

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of seven (7) residents (Resident #5) reviewed for accuracy of assessments. The facility failed to ensure Resident #5 was coded on her Quarterly MDS assessment, dated 05/07/2026, for having had weight loss of 11.9%, ten percent (10%) or more in the last six (6) months. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, 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 one of five residents (Resident #21) reviewed for care plans. The facility failed to update or add interventions to Resident #21's care plan given that the resident was positive for PASRR I at admissions (04/10/2026). This failure could place residents at risk of not receiving the necessary services or having the appropriate interventions to meet their current needs.

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 13 residents (Resident #28) reviewed for medication administration: The facility failed to ensure LVN H crushed and administered each of Resident #28's medications separately: baclofen 5 mg, cholecalciferol 25 mcg, loratadine 10 mg, docusate sodium 100 mg and hydroxyzine 25 mg via PEG-tube utilizing gravity according to the facility policy on 7/31/2026. This failure could place residents at risk of medication interactions and stress to the resident's gastrointestinal system, which could result in a change in condition.

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 1 of 3 residents (Resident #88) reviewed for infection control, in that: The facility failed to maintain standard infection control precautions while providing Resident #88 with perineal and catheter care. CNA's D and E did not perform hand hygiene and put on clean gloves when transitioning from a dirty to a clean procedure; did not use a new disposable wipe per stroke; cleaned the meatus while wearing dirty gloves; did not clean the indwelling catheter up to 4 inches; and did not replace the dirty brief for a clean brief. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect or exploitation or mistreatment, are reported 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 bodily injury, to the State Survey Agency for 1 of 3 residents (Resident #2) reviewed for freedom from abuse, neglect, and exploitation. The facility failed to report to the State Survey Agency (HHSC) an allegation of abuse when CNA C raised voice at a Resident #2 and called him a liar. This failure could place residents at risk for abuse and could lead to a diminished quality of life and harm.

Inspectors wroteBased on interview, observation, and record review, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized for 1 of 6 residents (Resident #1) reviewed medical records. The facility failed to document Resident #1's multiple bruises on her skin assessment dated [DATE]. These failures could place residents at risk for inaccurate medical records.

Inspectors wroteBased on 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 2 (Resident #2 and Resident #3) of 3 residents reviewed for pharmacy services. The facility failed to ensure Resident #2 had her prescribed controlled medication, Morphine Sulfate (Concentrate) Solution 20 MG/ML available to meet her needs, disposing of controlled medication consistent with standards of practice, and documenting the administration of medications. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 2 (Resident #2 and Resident #3) of 10 residents reviewed for medical records. The facility failed to maintain a medication administration record for Resident #2's controlled medication. The facility failed to maintain a medication administration record for Resident #3's controlled medication. These failures placed residents at risk for missed treatment and medications which could result in decline in health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure their posted nurse staffing information included the total number of actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift, in the facility reviewed for nurse staffing with 89 residents, in that: The facility's posted nurse staffing information did not include the actual hours worked by nursing staff. This failure placed residents at risk of not having accurate information posted about actual direct care hours worked and not receiving the appropriate level of care.

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 and misappropriation of resident property, are reported 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 for one of nine resident (Resident #2), in the facility reviewed for reportable events, in [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all alleged violations involving abuse/neglect/exploitation or mistreatment including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 24 hours if the events that caused the allegation did not involve abuse and did not involve serious bodily injury, to the administrator of the facility and other officials, including the State Survey Agency, in accordance with State Law through established procedures for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure Resident #1 had the proper medication given to the resident at the time of discharge. This deficient practice could place residents at risk of not being given proper medication on discharge resulting in an impaired health status.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a medication error rate below 5% for 28 medication administration opportunities with 3 errors resulting in a 10% medication error rate, for 2 of 4 (Residents #1 and #37) reviewed for medication administration. 1. The facility failed to ensure Resident #1 received medications Amiodarone (used to regulate rapid and/or irregular heart rhythms) and Apixaban (used to prevent blood clots) as ordered by the physician. 2. The facility failed to ensure Resident #37 received medication Xifaxan (used to treat the brain function decline that can occur secondary to liver damage) as ordered by the physician. These failures could result in residents not receiving the intended therapeutic benefits of medications.

Inspectors wroteBased on record review, interviews and observation, the facility failed to ensure residents (Resident #63) was able to communicate in preferred Language to caregivers for 1 of 4 residents reviewed for resident rights. Resident #63 who was English speaking only had difficulty communicating with primarily Spanish-speaking caregivers using communication tools. This failure could place residents at risk for not being informed about care and treatment that may affect resident's well-being and being able to participate in daily plan of care and delay in treatment.

Inspectors wroteBased on record review and resident interview, the facility failed to ensure resident of the right to participate in the development and implementation of his/her person-centered plan of care for 1 of 5 (Resident #61) residents reviewed for resident rights. The facility failed to invite and include the input of Resident #61 as members of the interdisciplinary team in Care Conference meetings. This failure could place residents at risk of not receiving the interventions, treatments, and care necessary for the resident to reach their highest practicable physical, mental, and psychosocial well-being by not involving the resident in Care Plan Conference meetings.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the use of the least restrictive alternative for the least amount of time and document ongoing re-evaluation of the need for restraints for 1 of 1 (Resident #81) residents reviewed for restraints. The facility failed to provide assessment, care planning, and ongoing re-evaluation of the use of a seatbelt restraint for Resident #81.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident assessments accurately reflected the resident's status for 1 of 8 residents (Resident #81) who were reviewed for resident assessments. The facility failed to document the use of a restraint device in Resident #81's quarterly MDS dated [DATE]. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

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 includes measurable objectives and timeframes to meet a resident's needs for 1 of 8 (#81) residents reviewed for comprehensive resident centered care. 1. The facility failed to provide care planning for the use of a wheelchair seatbelt restraint for Resident #81. 2. The facility failed to revise the comprehensive care plan for Resident #81 after hospitalizations resulting from the dislodgement of the resident's g-tube. This failure could lead to residents not receiving the care necessary to meet their highest practicable well-being.

Inspectors wroteBased on interviews, and record reviews, , the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 of 4 (#19) residents reviewed for quality of care in that: Resident #19's pacemaker maker, model, and additional information was not documented in his chart. This could affect residents with pacemakers and could result in residents not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive proper treatment and assistive devices to maintain vision abilities for 1 (Resident #12) of 1 residents reviewed for quality of care. The facility failed to provide necessary arrangements to repair broken eyeglasses for Resident #12. This failure could lead to injury and/or decreased quality of life.

Inspectors wroteBased on observation, resident and staff interviews, and record reviews, the facility failed to ensure that residents' environment remained as free of accident hazards as possible for 1 of 4 residents (Resident #14) reviewed for quality of care. The facility failed to ensure Resident #14 had cushioned hip covers (hipsters) in place at all times. This failure could place residents at an increased risk for injury related to falls.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure Food safety requirements to prepare, distribute and serve food in accordance with professional standards for food service safety for 1 of 5 (Cook D) kitchen staff working that day, in that: Cook D's beard/mustache restraint was off and exposed his thin mustache, while taking food temperatures on the steam table. This failure could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to handle and transport linens so as to prevent the spread of infection and to maintain an infection prevention and control program to provide a safe and sanitary environment to help prevent the developement and transmission of communicable diseases and infections for 3 of 7 residents (Residents #15, 75 and 139) reviewed for infection control. 1. The facility failed to ensure staff put soiled linen of Residents #15 and #75 into a container or bag prior to transporting. 2. The facility failed to ensure staff utilized PPE when providing high-contact care for Resident #139, whom was identified as requiring EBP. These failures could lead to the spread of infection and illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident #2) of 5 residents reviewed for medications. The facility failed to ensure Resident #2 received his Metoprolol succinate extended-release oral tablet 50 mg one time a day for hypertension from 09/14/2025 to 09/24/2024 (total 11 days) as ordered by the physician. The noncompliance was identified as PNC on 05/02/2025. The PNC began on 09/14/2024 and ended on 09/27/2024. The facility had corrected the noncompliance before the survey began. The deficient practice placed the residents at risk of not receiving desired outcomes from medications that are not administered according to physician's orders. Findings Included: [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #1) of 5 residents reviewed for medication administration. The facility failed to ensure when the ADON was administered medications to Resident #1 on 04/30/2025 at 9:00 am in the common area, the ADON said the resident's medications loud when other residents was also in the common area. This failure could place residents at risk of resident identifiable and medical information being accessed by unauthorized persons.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #2) of 5 residents reviewed for medical records. The facility failed to ensure LVN A documented Resident #2's blood pressure after re-checking the blood pressure when MAC notified LVN A the resident's blood pressure was 101/34 on 04/05/2025. This failure placed resident at risk for missed treatment and care which could result in decline in health and well-being.

Inspectors wroteBased on observations, 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 of communicable diseases and infections for 1 (Resident #3) of 5 residents reviewed for infection control practices. The facility failed to ensure the ADON sanitized or washed her hands before administering medications to Resident #3. This deficient practice could place residents at risk for cross contamination and infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 out of 6 residents (Resident #1) reviewed for quality of care. 1. The facility failed to ensure Resident #1's wounds were measured weekly on (9) occasions. 2. The facility failed to ensure wound care treatments/dressings were provided to Resident #1 as ordered by the physician on (2) occasions. This deficient practice could place residents at risk for worsening wounds and/or infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 1 (Resident #2) resident reviewed for pressure ulcers received necessary treatment and services, consistent with profession standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing. 1. The facility failed to provide wound care treatments/dressing to Resident #2 as ordered by the physician on (22) occasions. 2. The facility failed to ensure LVN K followed physician orders during observed wound care for Resident #2's right lateral foot on 02/19/2025. 3. The facility failed to ensure LVN K documented a verbal order for wound care for the right lateral foot on 02/18/2025. This deficient practice could place residents at risk for worsening wounds and/or infections. [...]

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 6 residents (Resident #1, Resident #3, Resident #4, and Resident #6) reviewed for accuracy of records. 1. The facility failed to ensure Resident #1's treatments were documented per facility policy on (5) occasions. 2. The facility failed to ensure Resident #3's treatments were documented per facility policy on (17) occasions. 3. The facility failed to ensure Resident #4's treatments were documented per facility policy on (13) occasions. 4. The facility failed to ensure Resident #6's wound assessment was documented per facility policy. These deficient practices could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program as described at §483.80(a)(2). 18 of 28 nurses (LVN B, LVN D, RN G, RN H, LVN K, RN L, LVN P, LVN Q, LVN T, RN U, LVN V, LVN W, RN X, RN Y, LVN AA, LVN DD, LVN EE, and LVN FF) reviewed for hand hygiene training, 18 of 28 (LVN B, LVN F, RN G, RN H, RN J, LVN P, LVN Q, LVN T, RN U, LVN V, LVN W, RN Y, LVN AA, LVN BB, LVN DD, LVN EE, LVN FF, and ADON) reviewed for hand hygiene competency, and 28 of 28 (LVN B, LVN D, LVN F, RN G, RN H, LVN I, RN J, LVN K, RN L, LVN M, LVN P, LVN Q, LVN R, RN S, LVN T, RN U, LVN V, LVN W, RN X, RN Y, LVN Z, LVN AA, LVN BB, LVN CC, LVN DD, LVN EE, LVN FF, and ADON) reviewed for wound care training. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure that pain management is provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 out of 4 residents (Resident #6) reviewed for pain management. The facility failed to adequately assess and treat Resident #6's pain prior to or during wound care. This failure could place residents at risk for unnecessary pain, discomfort, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 6 medication carts (Treatment Cart) reviewed for medication storage. The facility failed to ensure the Treatment Cart was locked when unattended on (3) occasions. This failure could place residents at risk of medication misuse and drug diversion.

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 2 of 2 residents (Resident #2 and Resident #3) reviewed for infection control. LVN K and RN L did not perform hand hygiene appropriately when providing wound care to Resident #2 and Resident #3. This deficient practice could affect all residents who require wound care and place them at risk for infection.

Inspectors wroteBased on observation, 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 1 of 3 residents (Resident #1) reviewed for pharmacy services in that: The facility failed to follow physician orders for the fentanyl patch resulting in Resident #1 becoming unresponsive and suffering respiratory failure. An Immediate Jeopardy was identified on 7/25/24 at 3:15 PM. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as described in the plan of care for 2 of 3 staff (LVN B and LVN F) reviewed for nursing competencies, in that: The facility failed to ensure LVN B and LVN F followed physician's fentanyl order which resulted in Resident #1 becoming unresponsive and suffering respiratory failure. This failure could place residents at risk for not having medications accurately dispensed, not receiving the intended therapeutic effects of their medications and could contribute to possible adverse reactions.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement a comprehensive care plan to meet the medical and nursing needs and the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being of 1 (Resident #1) of 5 residents reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #1 requiring weekly skin assessments. This failure could place residents of risk for not receiving appropriate care and treatment, worsening of skin issues, a delay in treatment, a decline in health, and hospitalization.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 24 Residents (Residents #15, #47 and #50) reviewed for safety, monitoring, and supervision. 1. The facility failed to monitor and supervise Resident #50's multiple incidents of drinking beer and receiving quetiapine (used to treat the symptoms of mental illness that caused disturbed or unusual thinking), Zolpidem (used to treat difficulty falling asleep or staying asleep; a class of medications called sedative-hypnotics) and hydrocodone (a narcotic analgesic agent for the treatment of moderate to moderately severe pain) with subsequent falls, possession of cigarettes and a personal lighter while assessed as a smoker who needed supervision. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 24 residents reviewed for medication storage. 1. The facility failed to store Resident #52's medications which were kept at her bedside which resulted in an incident on 11/22/2023, when she was hospitalized and diagnosed with overdose related to self-medication with Diphenhydramine (an antihistamines; used for relief from symptoms related to hay fever, upper respiratory allergy, or cold symptoms) and hydrocodone (a narcotic analgesic agent for the treatment of moderate to moderately severe pain). An Immediate Jeopardy (IJ) was identified on 03/29/2024. [...]

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. Sanitizing buckets were not stored away from food products on 03/24/24. 2. Personal beverages were in a part of the kitchen work area on 03/24/24. 3. The juice machine was not clean on 03/24/24. 4. A couple of milk jugs were opened and not dated on 03/24/24. 5. There was a prepared salad in the refrigerator that was not discarded on the discard date of 03/20/2024. 6. There was a package of cheese stored in the freezer that was open and exposed to the inner freezer environment on 03/24/24. 7. There was not a discard date for cooked eggs that was stored in the freezer with only one date: 3-23 on the package. 8. [...]

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 source and misappropriation of resident property, are reported 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, for 4 of 24 residents (Residents #15, #50, #52, and #47) reviewed for allegations of abuse, neglect, exploitation, and mistreatment, in that: 1. [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure residents who are 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 24 residents (Resident #12) reviewed for assistance with showers. The facility failed to provide Resident #12 a shower for 7 days . This failure could place residents at risk for demoralized self-esteem and risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide resident preferences for individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 2 of 8 residents (Resident #48 and Resident #62) reviewed for activity preference, in that: The facility failed to ensure Resident #48, and Resident #62 received 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 observation, interview, and record review the facility's interdisciplinary team failed to review and revise the care plan after each assessment, including both the comprehensive and quarterly review assessments for 3 of 32 residents (Resident #18) reviewed for revised care plans in that: 1. The facility failed to ensure Resident #18's use of dentures was care planned. 2. The facility failed to ensure Resident #8's care plan was updated after an attempted elopement. These failures could place residents at risk for not receiving appropriate interventions to meet their current and changing needs.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to assist residents in obtaining routine dental services and assist the resident with making appointment for 2 of 8 (Residents #18 and #81) residents reviewed for dental services in that: 1. The facility failed to assist Resident #18 in obtaining appropriate dental services after Resident #18's upper dentures became loose and were recommended to be replaced by the dentist. 2. The facility failed to assist Resident #81 in obtaining appropriate dental services after Resident #81 and Resident #81's family requested it due to lack of natural teeth per her annual MDS assessment dated [DATE]. This deficient practice could affect residents who had dentures and place them at-risk by contributing to mouth pain, difficulty eating and weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide and document sufficient preparation to ensure safe and orderly discharge from the facility for 2 of 3 residents (Resident #2 and #3) reviewed for discharge. 1. The facility failed to ensure Resident #2's home health services and DME were arranged and in place prior to discharge. 2. The facility failed to ensure Resident #3's home health and wound care services were confirmed and in place prior to discharge. These failures could place residents at risk of being discharged without preparation, causing a disruption in their care and place the residents at risk for their needs not being met.

Inspectors wroteBased on interview and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 of 3 staff (Staff C) reviewed for staff qualifications. The facility failed to ensure Staff C was appropriately licensed to practice social work in the State of Texas. This failure could place residents at risk of not receiving care and services from staff who were properly trained and supervised.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' right to formulate an advance directive for 1 of 8 residents (Resident #1) reviewed for advanced directives, in that: The facility failed to ensure Resident #1's Out-of-Hospital Do Not Resuscitate (OOH DNR) was dated and signed by two witnesses to the resident's signature which made the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 3 residents (Resident #2 and #3) reviewed for comprehensive care plans in that: 1. The facility failed to ensure Resident #2's care plan included discharge planning and goals. 2. The facility failed to ensure Resident #3's care plan included discharge planning and goals. These failures could affect residents and place them at risk of their discharge wishes not being honored and not receiving appropriate treatment and services on discharge:

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 43% based on 28 errors out of 64 opportunities, which involved 4 of 6 residents (Resident #3, Resident #4, Resident #5, and Resident #6) reviewed for medication errors. - LVN A failed to administer medications as ordered to Resident #3 by administering Aspirin (a blood thinner), Calcium supplement, Cyclosporine (eye drops), Apixaban (a blood thinner), Fenofibrate (a treatment for high cholesterol), Gabapentin (a treatment for nerve pain), multivitamin supplement, Omega-3 supplement, Polyethylene Glycol (a treatment for constipation), Risperidone (a treatment for mood disorder), and Tamsulosin HCl (a treatment for an enlarged prostate) over 1 ½ hours after the scheduled time. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide reasonable accommodation of resident needs 2 of 12 resident rooms (Resident #1 and Resident #2) reviewed for call lights. The facility failed to ensure Resident #1 and Resident #2's call lights were within reach and placed for easy access. The deficient practice could place residents at risk of not receiving care or attention needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for 1 of 29 residents (Resident #1) records reviewed for treatment documentation. LVN B documented on 06/22/2023 Resident #1 returned from an offsite appointment at 07:00 p.m. and documented Resident #1 received his 04:00 p.m. medications Furosemide, Buspirone HCl, Lactulose Encephalopathy, Carbidopa-Levodopa without notating the medications were administered late. These failures could place residents at risk of the medical record by not being an accurate representation of their medical condition or medical needs.