Treviso Transitional Care

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing at least 30 days before the resident is transferred or discharged or as soon as practicable before transfer or discharge 1 of 2 resident (Residents #1) reviewed for transfer and discharge. The facility failed to provide notice to the Office of the State Long-Term Care Ombudsman of the transfer of Resident #1 on 05/11/2026 with a written discharge/transfer notice. This failure could place residents at risk of improper discharge planning and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility has failed to ensure that the resident environment remains as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 5 residents reviewed for accidents. (Resident #1)The facility failed to notify nursing staff when CNA B and CNA C found Resident #1 on the floor after an unwitnessed fall. The facility failed to complete an assessment on Resident #1's unreported fall. This failure could place residents at risk for injury or delayed treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment and clean bed linens for 4 of 6 residents (Resident #'s 12, 30, 34, and 39) reviewed for a homelike environment. The facility failed to ensure Resident #12's floor was free of debris, dust, shreds of papers, and five thick white hardened puddles of a substance on the floor beside and under the bed. The facility failed to ensure Resident # 30, Resident #34, and Resident #39 's bed linens were changed. These failures could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to promptly resolve grievances for 1 of 6 residents (Resident #54) reviewed for grievances. The facility did not ensure Residents #54 grievances related to meals being served late was resolved. The facility did not ensure the grievance received during Resident Council related to meals being served late on 03/07/2025, 04/04/2025, 06/02/2025, and 07/03/2025 were resolved. These failures could place residents at risk for grievances not being addressed and resolved promptly, hunger, frustration and low blood sugars.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 5 of 22 residents reviewed for care plans (Resident #3, Resident # 5, Resident # 8, Resident # 75, Resident #97)The facility failed to ensure Resident #3's diagnosis of diabetes was coded on the quarterly MDS on 6/5/2025 and care planned. The facility failed to ensure Resident #5's bathing type/preference was care planned on 5/22/2025. The facility failed to ensure Resident #8's seatbelt restraint on wheelchair was care planned with interventions on how to monitor. The facility failed to ensure Resident #75's swallowing difficulties, coded on his 8/9/25 admission MDS assessment was care planned. The facility failed to ensure Resident #75's active discharge planning was care planned. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practices for 4 of 17 residents (Resident #40, Resident #13, Resident #41, Resident #97) reviewed for respiratory care.1. The facility failed to ensure Resident #40's oxygen was placed on 2 liters per minute via nasal cannula as ordered by the physician.2. The facility failed to ensure Resident #13 had a physician order for her tracheostomy (is a medical device inserted into the trachea (windpipe) to establish an airway for breathing) type, size, configuration, and inflated or deflated. On 8/24/25, Resident #13 had a Shiley (type of tracheostomy tube) 6.0 XLT (Extended-Length), deflated cuffed tracheostomy. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine dental care for 3 of 3 (Resident's #35, #100, and #37) residents reviewed for dental services. The facility failed to ensure adequate follow-ups were completed on dental referrals for Residents #35, #100, and #37. This failure could affect residents by placing them at risk for oral complications and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident receives and the facility provides food that accommodates residents' food preferences for 4 of 22 residents (Resident#13, Resident #41, Resident #75, and Resident #97) reviewed for the accommodation of resident's meal choices. The facility failed to ensure Resident#13, Resident #41, Resident #75, and Resident #97 meal choices were honored. This failure could result in a decrease in resident choices, diminished interest in meals, and weight loss.

Inspectors wroteBased on observations, 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 and transmission of communicable diseases and infections for 1 of 22 residents (Residents #9), 1 of 1 laundry rooms, and 1 of 6 halls (Hall 100) reviewed for infection control practices. 1. The facility failed to ensure Resident #9's urinary catheter bag was not touching the floor on 8/26/25. 2. The facility failed to ensure the Housekeeping/Laundry Supervisor L did not let clean blankets touch the floor during the folding process on 8/26/25. 3. The facility failed to ensure proper infection control measures when CNA D served ice from the ice chest cooler located on Hall 100 on 08/24/2025. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 2 of 22 residents (Resident #9 and Resident #25) reviewed for resident rights.1. The facility failed to ensure Resident #9's urinary catheter bag was covered with the privacy cover flap. 2. The facility failed to ensure CNA D and CNA G knocked on Resident #25's door before entering on 8/25/25.3. The facility failed to ensure CNA D and CNA G closed Resident #25's privacy curtain during catheter care on 8/25/25.4. The facility failed to ensure CNA D and CNA G properly covered Resident #25 during catheter care on 8/25/25. These failures could place residents at risk of humiliation, diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 of 22 residents (Resident #61) reviewed for notification of change. The facility failed to notify the NP/MD of Resident #61's complaint of left foot pain on 8/21/25. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the right to be free from any physical restraints imposed for purposes of convenience and not required to treat medical symptoms for 1 of 1 resident reviewed for restraint use (Resident #8). The facility failed to ensure Resident #8 was free from physical restraints in the form of seatbelt located on the wheelchair that Resident #8 was unable to remove independently. This failure could place residents at risk for a decreased quality of life, a decline in physical functioning and injury.

Inspectors wroteBased on interviews and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 22 residents (Resident #3) reviewed for MDS assessment accuracy. The facility did not ensure Resident #3's quarterly MDS identified a diagnosis of Diabetes and use of insulin. These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide the resident and their representative with a summary of the baseline care plan for 2 of 6 residents (Resident #60 and Resident #114) reviewed for baseline care plans. The facility failed to provide Resident #60 and Resident #114, a copy of the summary of their baseline care plans. This failure could place residents at risk of not knowing their care and needs provided by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 17 residents reviewed for ADLs (Residents #59.) The facility did not clean or trim Resident #59's fingernails. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #3) reviewed for accidents and supervision. The facility failed to ensure CNA G performed a safe mechanical lift transfer for Resident #3. This failure could place residents at risk of injury.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure a resident with urinary incontinence, based on the resident's comprehensive assessment, received appropriate treatment and services to prevent urinary tract infections (UTI) for 1 of 2 residents (Residents #25) reviewed for urinary catheters. The facility failed to ensure Resident #25 had an indwelling (foley) catheter securement device on 8/25/25. The facility failed to ensure on 8/25/25, CNA D provided catheter care per the facility's policy and procedure on Resident #25. These failures could place residents at risk for indwelling urinary catheter dislodgement, urethral (empties urine from the bladder and out of the body) damage, pain, and urinary tract infections.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had 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 others for 1 of 6 residents (Resident #1) reviewed for reasonable accommodations of needs . The facility failed to ensure Resident #1 had a functioning call light. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs.

Inspectors wroteBased on interview, and record review, the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response in a timely manner 3 (February, March, and April 2024) of 6 months reviewed for resident group response, in that: The documentation of the facility's effort to resolve resident grievances of medicine being left at bedside, not having their beds made, bedding not being changed on shower days, no snacks being provided, and the facility running out of toilet paper collected at Resident Council meetings on 02/01/2024, 03/21/2024, and 04/04/2024 were not made until between 05/07/2024 and 05/18/2024. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure each Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 4 of 32 residents (Resident #149, Resident #24, Resident #16, and Resident #5) reviewed for MDS transmittal. The facility did not ensure Resident # 149's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days The facility did not ensure Resident # 24's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days . The facility did not ensure Resident # 16's quarterly MDS assessment dated [DATE] was completed and successfully electronically transmitted within 14 days . [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. 1. The facility failed to store all cardboard boxes off the floor. 2. The facility failed to ensure the outside of the microwave and the wall next to the beverage table was clean and sanitary. 3. The facility ensure that all food items in the freezer and walk in cooler were properly dated and labeled. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on interview and record review, the facility failed to complete a resident assessment within the required time frame for 3 of 15 residents (Resident 24, Resident 16, Resident #5) reviewed for quarterly assessments. Resident #24's Quarterly MDS dated [DATE], was not completed until 7/8/24. Resident #16's quarterly MDS dated [DATE], was not completed until 7/5/24. Resident #5's quarterly MDS dated [DATE], was not completed until 7/5/24. This failure placed residents at risk of not having their assessments completed timely which could result in not having their individually assessed needs met.

Inspectors wroteBased on interview and record review the facility failed to ensure that resident assessments accurately reflected the resident's status for 1 (Resident #13) of 12 residents reviewed for accuracy of resident assessments. The facility failed to ensure that Resident #13's MDS 05/05/2024 quarterly assessment accurately reflected the resident's history of falls. This failure put residents at increased risk of staff not being aware of resident needs due to inaccurate assessments.

Inspectors wroteBased on interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 2 (Resident #13 and Resident #44) of 10 residents reviewed for care plans. 1. The care plan for Resident #13 did not address the diagnosis and treatment for Parkinson's Disease. 2. The care plan for Resident #44 did not address a significant weight loss of greater than 10% in 180 days. These failures could place residents at risk of not having their individualized needs met, falls, weight loss and a decline in their quality of care and life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 of 13 residents (Residents #13 and Resident #44) reviewed for care plans. 1. The facility failed to revise and update Resident #13's nutrition care plan with the diet change of puree diet with honey thickened liquids. 2. The facility failed to revise and update Resident #44's comprehensive care plan about her discontinued IV medications, discontinued use of a foley catheter, healed DTI to left heel, tobacco use, antibiotic use, UTI diagnosis, hypnotic use, anticoagulation use, and healed pelvic abscess. These deficient practices could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who need respiratory care are provided with such care, consistent with professional standards of practices for 1 or 8 residents (Resident #24) reviewed for respiratory care. The facility failed to change the oxygen tubing for Resident #24. These failures could place residents at risk for of respiratory infections.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 4 residents reviewed for pharmacy services (Resident #42) 1. The facility failed to keep a record receipt of Resident #42's-controlled medication Hydrocodone. The failures could place residents at risk of not having accurate records of medication administration which could result in diminished health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (a medication used: in excessive doses (including duplicate therapy) for 1 of 6 residents (Resident #54) reviewed for unnecessary medications The facility failed to ensure Resident #54 did not receive duplicate medication therapy for metoprolol (blood pressure medication), venlafaxine (antidepressant), trazadone (antidepressant used as sleep aide), pantoprazole (acid-reflux medication), MiraLAX (laxative), and vitamin D3. This failure could place residents at risk for adverse drug reactions (unintended, harmful events attributed to the duplicate use of these medications) and receiving unnecessary medications.

Inspectors wroteBased on observation, record review, and interview, the facility failed to store all drugs and biologicals in locked compartments for 1 of 5 medication carts (400/500 hall cart) reviewed for pharmacy services. 1. The facility failed to lock 1 medication carts for hall 400/500 medication cart. These failures could place residents at risk of not having their medications available as prescribed, a drug diversion, and an adverse reaction.

Inspectors wroteBased on, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 2 of 6 residents reviewed for pharmacy services. (Resident # 1 and Resident #2) 1. The facility failed to administer 14 of 30 scheduled doses of the medication glipizide (used of treatment of diabetes mellitus type 2) 2.5 mg once daily before breakfast and omeprazole 20mg once daily before breakfast (used to treat GERD) timely for Resident #1 in January 2024. 2. The facility failed to administer 6 out of 21 doses of Synthroid (used to treat thyroid hormone imbalance) 100 micrograms daily in July 2023 for Resident #2. These failures could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life or death.

Inspectors wroteBased on interview and record review, the facility failed to operate and provide services in compliance with all applicable Federal, State, and local laws, regulations, and codes, and with accepted professional standards and principles that apply to professionals providing services in such a facility for 1 or 6 employees (RN H) personnel files reviewed. -The facility failed to notify the Texas Board of Nursing as noted under employment requirements of the court order from the Texas Board of Nursing signed on 05/04/2016 of the employment of RN H. in August 2023. -The facility failed to submit a criminal background check for RN H prior to employment in August 2023. These failures placed the residents at risk of abuse, neglect, and exploitation.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse for 1 of 24 residents (Resident #5) reviewed for resident abuse. The facility failed to ensure Resident #5 was free from abuse, as a result Resident #5 was verbally assaulted by CNA A. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 2 of 24 residents reviewed for misappropriation of resident property. (Resident #3 and Resident #4) The facility failed to prevent CNA E from stealing a $25.00 gift card and some change from Resident #3. The facility failed to prevent misappropriation of property when CNA A took Resident #4's box of sodas. These failures could place residents at risk for decreased quality of life, misappropriation of property, and dignity.

Inspectors wroteBased on interview, and record review, the facility failed to implement its written polices, and procedures that prohibit abuse, neglect, and exploitation for 2 of 6 staff (RN H and CNA J) reviewed for neglect and abuse policies. The facility failed to conduct a criminal background check on RN H and CNA J in 2023. This failure could put residents at risk of receiving services from employees with a history of misconduct and/or were ineligible to provide services in this setting.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 24 residents reviewed for care plans (Resident #6). The facility failed to implement 2-person assistance during transfers for Resident #6. This failure could place residents at an increased risk of injury during transfers, a decline in physical or functional well-being and care needs not being met.

Inspectors wroteBased on interviews and record review the facility failed to ensure allegations of neglect were thoroughly investigated to prevent further elopement and report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency within 5 working days of the incident and if the alleged violation is verified appropriate corrective action must be taken for 1 (Resident #1) of 4 residents reviewed for neglect. The facility failed to immediately investigate, protect the resident, and report allegations of neglect when: Resident #1 eloped from the facility for an unknown amount of time and was found down the street approximately 150 yards from the facility by law enforcement. She had crossed a street and was in a 30 mile per hour area. [...]

Inspectors wroteBased on interviews, and record review the facility failed to provide adequate supervision to prevent elopement for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, and supervision in that: Resident #1 eloped from the facility for an unknown amount of time and was found approximately 150 yards away from the facility by a neighboring facility and law enforcement. She had crossed a street and was in a 30 mile per hour area. An Immediate Jeopardy (IJ) was identified on 11/4/23 at 7:25 p.m. While the IJ was removed on 11/6/23 at 11:20 a.m., the facility remained out of compliance at no actual harm with a potential for more than minimal harm that is not an Immediate Jeopardy and a scope of isolated due to the facility's need to evaluate the effectiveness of their corrective systems. This failure could affect residents by placing the residents at risk for harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse/neglect were reported immediately, but no later than 24 hours of the event to the State Agency, in accordance with state law through established procedures for 1 (Resident #1) of 4 residents reviewed for neglect. The facility failed to report the elopement of Resident #1 to the State Agency in the allotted time frames set forth by the State Agency. This failure could place Resident #1 at risk for neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to immediately consult with the resident physician when there was a significant change in the resident physical condition for 1 of 6 residents reviewed for change in condition. (Resident #1) The facility failed to notify the physician when Resident #1 experienced nausea and vomiting for 3 days after receiving new medications. Resident #1 was prescribed 5 different medications on 9/27/23 and 4 of them had side effects of nausea and vomiting. Resident #1 received the medications on 9/27/23. She vomited on 9/28/23, 9/29/23 and 9/30/23 and nurses noted in the clinical record no adverse reactions to medications. On 10/1/23 Resident #1 was sent to the ER with decreased blood pressure, decreased heart rate, and oxygen levels. On arrival to the hospital, she was found to have a low body temperature and sepsis. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident received the treatment and care in accordance with professional standards of practice for 1 of 5 residents reviewed for quality of care.(Resident #1), in that: The facility failed to ensure Resident #1 was not having adverse reactions to new medication. Resident #1 was prescribed 5 different medications on 9/27/23 and 4 of them had side effects of nausea and vomiting. Resident #1 received the medications on 9/27/23. She vomited on 9/28/23, 9/29/23 and 9/30/23 and nurses noted in the clinical record no adverse reactions to medications. They failed to assess Resident #1 and notify the physician when she experienced adverse reaction to new medications. On 10/1/23 Resident #1 was sent to the ER with decreased blood pressure, decreased heart rate, and oxygen levels. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident had the right to a dignified existence for 1 or 5 residents reviewed for rights (Resident #2.) Resident #2 was embarrassed due to being sent to the hospital ER with a hospital gown and a brief. The brief was showing from the back of the chair. This failure caused the resident embarrassment and did not promote a dignified existence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision for 1 of 5 residents reviewed for supervision. (Resident #2) The facility did not supervise Resident #2 when staff dropped her off at a local emergency room alone and confused. This failure could place residents at risk of injury or harm.

Inspectors wroteBased on interview and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who completed a training course approved by the State for 1 of 1 facility reviewed for Activity Director qualifications. The facility did not ensure the Activity Director was qualified to serve as the director of the activities program. This failure could place residents at risk of not receiving a program of activities that met their assessed activity needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide residents with food and drink that was palatable, attractive, and at a safe and appetizing temperature for five of six residents (Residents #29, #23, #37, #42 and #76) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #29, Resident #23, Resident #37, Resident #42, and Resident #76, who complained the food was served cold and did not taste good. This failure could place residents at risk of decreased food intake, weight loss, altered nutritional status, and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 5 of 5 residents (Residents #35, #42, #45, #70 and #136) reviewed for infection control practices. The facility failed to ensure the proper disinfectant cleaner was used to clean Resident #42's isolation room with clostridium difficile (bacteria that causes infection in the large intestine). CNA N failed to handle Resident #70's dirty linen properly. CNA L failed to remove her dirty gloves and perform hand hygiene during Resident #136 incontinent care. The facility failed to ensure CNA N and CNA R performed hand hygiene while providing incontinent care for Resident #45 and Resident #35. [...]

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all existing staff, consistent with their expected roles for 3 of 21 employees (Activity Director, Maintenance Supervisor and the Housekeeping Supervisor) reviewed for required trainings. The facility failed to ensure the Activity Director, Maintenance Supervisor and the Housekeeping Supervisor received restraint and HIV training annually. This failure could place residents at risk for inappropriate restraints and exposure to HIV.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, at the time each resident was admitted , there were physician orders for the resident's immediate care for 1 of 3 residents reviewed for admission physician orders. (Resident #70) The facility failed to ensure Resident #70 had a physician's order for the use of her life vest (personal defibrillator). This failure could place residents at risk of not receiving appropriate care and treatment services.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial need identified in the comprehensive assessment for 2 of 3 residents reviewed for care plans. (Resident #70 and Resident #39) 1. The facility failed to schedule Resident #70 a cardiology appointment according to her discharge orders. 2. The facility failed to ensure Resident 39's care plan was updated to include psychotic medication of lorazepam (anxiety medication). These failure could place the residents at increased risk of not having their needs met and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to review and revise the person-centered care plan to reflect the current condition for 1 of 7 (Resident #39) residents reviewed for care plan revisions. The facility failed to ensure Resident 39's care plan to discontinued psychotic medication of Risperdal (mood disorder medication). This deficient practice could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 6 residents reviewed for ADLs. (Resident #1) The facility failed to ensure Resident #1 was routinely showered. This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 2 of 7 residents (Residents #37 and #56) reviewed for respiratory care. 1. The facility failed to ensure Resident #37 had a clean oxygen concentrator filter in place. 2. The facility failed to properly store the HHN tubing for Resident # 56. These failures could place residents at risk for respiratory infections and exacerbation of respiratory disease. Findings Include: 1. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure nurse aides were able to demonstrate competency in skills and necessary techniques to care for resident's needs, as identified through resident assessments and described in the plan of care for 1 of 4 CNAs (CNA L) reviewed for nurse aide competencies. The facility failed to ensure CNA L was proficient with hand hygiene and glove changes with incontinent care skills. This failure could place residents at an increased and unnecessary risk of exposure to staff who lack the appropriate skill competencies to provide incontinent care that was capable of minimizing urinary tract infections.

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 2 of 6 residents (Resident #56 and Resident #78) reviewed for safe functional equipment. 1. The facility failed to ensure Resident #56 had a functioning wheelchair brake. 2. The facility failed to ensure Resident #78's wheelchair seat was not torn. These failures could place residents at risk for skin issues, discomfort, and falls.