Uvalde Healthcare and Rehabilitation Center

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that at the time each resident was admitted , the facility must have physician orders for the resident's immediate care, for 1 of 8 residents (Resident #31) reviewed for isolation contact precautions and intravenous line maintenance orders. Resident #31 was admitted on [DATE] with an immediate need for isolation contact precautions (essential measures in healthcare settings to prevent the spread of infections, particularly those that can be transmitted through direct or indirect contact with patients or their environment) and intravenous access maintenance, which he did not receive for 4 days until 5/26/2026. These failures could place residents at risk for delayed care and the spread of infectious disease.

Inspectors wroteBased on interviews, and record reviews, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care. The baseline care plan must be developed within 48 hours of a resident's admission; include the minimum healthcare information necessary to properly care for a resident, for 1 of 8 residents (Resident #31) reviewed for care plans for immediate needs. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure 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 describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 (4) residents in that: Resident #4's Care Plan did not include his diagnosis of PTSD and interventions. This could affect all residents with care plans and could result in a decrease in care.

Inspectors wroteBased on observations, interviews, and record reviews, 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 8 residents (Resident #31) reviewed for continuity of care. CNA E entered Resident #31's isolation contact precautions room without personal protection equipment (PPE). This failure could place residents at risk of the spread of infectious diseases.

Inspectors wroteBased on observations and interviews, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition, for 1 of 1 laundry departments reviewed for laundry equipment. 1 of the 2 commercial washing machines was inoperable for longer than 8 months. This failure could place residents at risk for not having timely laundry service.

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 1 of 1 (1 hair salon, 1 kitchen) facility in that: The kitchen drains on floor, near the dish machine, did not have a grate on it. Hair salon was not sanitary, including 3 brushes with hair, hair on several hair curlers and the sink drain filter had a glob of hair. These failures could place residents at risk by residents' germs being spread, that use the hair salon and could allow pests to enter the facility through the kitchen floor open drain.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain effective pest control for 1 of 1 kitchen reviewed for pests. The facility failed to have pest control effectively treat the kitchen for roaches. This deficient practice could place residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 6 (1/18/25, 1/19/25, 1/25/25, 1/26/25, 2/8/25, and 2/9/25) of 90 days reviewed for RN hours reviewed, for the months January 1st, 2025, through March 31st, 2025. The facility failed to have RN coverage for 6 days on Saturday 1/18/25, Sunday 1/19/25, Saturday 1/25/25, Sunday 1/26/25, Saturday 2/8/25, and Sunday 2/9/25. This failure could place residents at risk for harm by denying residents the advanced critical thinking skills a registered nurse could provide.

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 disease and infection for 2 of 8 residents (Resident #1 and Resident #21) reviewed for infection control: 1. The facility failed to ensure CNA A and another unidentified CNA wore the proper PPE while transferring Resident #21 who was on EBP. 2. The facility failed to ensure LVN C did not touch the sink handle in Resident #1's bathroom with her bare hands after washing her hands. 3. The facility failed to ensure laundry aide E did not have food and drinks in the laundry room on the laundry folding table. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observation, 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 for 1 of 8 residents (Resident #21) reviewed for care plans: The facility failed to ensure Residents #21's Care Plan reflected he was on EBP (Enhanced Barrier Precautions). This deficient practice could cause confusion for staff members responsible for providing direct care to the residents and place residents at risk of receiving improper care and services.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 of 6 (Resident #1) residents reviewed for respiratory care. The facility failed to ensure Resident #1's oxygen concentrator filter was cleaned and free of debris. This deficient practice could place residents at risk for an increase in respiratory complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #20) reviewed for dialysis: The facility failed to fully complete the dialysis communication forms for Resident #20 on 3/24/25 and 3/31/25. This failure could affect residents who received dialysis treatments and place them at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview and record review revealed the facility failed to ensure correct use of bed rails including but not limited to the following elements. Assess the resident for risk of entrapment from bed rails prior to installation and obtain informed consent prior to installation for 1 of 8 Residents (Resident #20) whose records were reviewed for bed rails. The facility failed to ensure staff obtained informed consent (the facility has explained to the resident or RP the risk and benefits of using bedrails) for the use of 1/4 bed rails for Resident #20. These deficient practices could affect residents who used bed rails and could put the residents at risk for potential injuries. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 6.67% based on 2 out of 30 opportunities, which involved 2 of 3 Residents (Resident #1 and Resident #35) reviewed for medication administration, in that: 1. The facility failed to ensure LVN C administered Resident #1's insulin lispro (fast-acting insulin that starts to work about 15 minutes after injection, peaks in about 1 hour, and keeps working for 2 to 4 hours) correctly. 2. The facility failed to ensure MA B administered the full dose of Resident #35's polyethylene glycol 3350 (osmotic laxative that attracts water into the colon to ease, hydrate, and soften stool). [...]

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements. The DM did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 facility reviewed for dietary requirements: The DS did not have the appropriate certification, education, or qualifications to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.

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: 1. The facility failed to store, label and date food items properly in 3 of 3 reach in freezers. 2. The DS, Cook, and Dietary Aide C were not wearing hair restraints properly during food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meal reviewed for food and nutrition services in that: The facility failed to ensure Resident #1 received a health shake with his lunch meal on 10/3/24. This failure could place residents at risk for dissatisfaction, poor intake, weight loss, and diminished quality of life.

Inspectors wroteBased on interviews, and record reviews the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 3 residents (Resident #1) reviewed in that: CNA A failed to follow the plan of care which required a 2 person assist to transfer Resident #1 with the Hoyer Lift (a mechanical lift that uses a sling attached to a hoist to transfer a person from a bed to a wheelchair) on 03/23/24. This failure resulted in the identification of Immediate Jeopardy (IJ) on 3/23/24 at 6:53 p.m. While the immediacy was removed on 3/28/24 at 3:42 p.m., the facility remained out of compliance at scope of isolated and a severity with actual harm due to the facility's need to monitor the implementation of the plan of removal. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #1) reviewed for accidents, hazards, and supervision in that: CNA A failed to follow Resident #1's physician order and plan of care which required a 2-person assist to transfer Resident #1 with a Mechanical Lift (a mechanical lift with a sling attached to a hoist to transfer a person from a bed to a wheelchair) on 03/23/24, which resulted in the back of Resident #1's wheelchair to recline as he was placed in it and caused an injury to his right foot when his foot hit the floor. Resident #1 was transferred to a local hospital and was diagnosed with a fracture of the right 5th metatarsal bone (break in the little toe). [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure residents had the right to be informed of, and participate in, his or her treatment, including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she prefers, for 1 of 16 residents (Resident #14) reviewed for advance education for medication benefits versus risks. The facility administered medroxyprogesterone, a type of hormone (progestin), from June 2023 to March 2024 to Resident #14 without Resident #14 and/or Resident #14's representative receiving education on the rationale for the prescription, the benefits vs. the risks of medroxyprogesterone and offered options for treatment. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for 2 of 18 residents (Residents #14 and #23) reviewed for physician notification of changes. 1 . The facility failed to inform Resident #14's physician when Resident #14 made sexual lewd comments towards female residents and entered Resident #23's shower room while she was showering on 02/06/2024 and again on 03/12/2024 and unsuccessfully attempted to enter Resident #23's shower room on 02/15/2024. 2. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure Residents had the right to be free from abuse, neglect, and involuntary seclusion for 3 (Resident #23, #43, and #1) of 16 residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #23 was not neglected when she was left in a dark, locked, shower room alone. 2. The facility failed to protect Resident #23 from abuse by allowing a male resident access to her while in the shower. 3. The facility failed to protect Resident #1 when she wandered into Resident #43's room and Resident #43 hit her (Resident #1) on the head. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that Residents environments remained as free from accident and hazards as possible, and each resident received adequate supervision and assistive devices to prevent accidents for 2 of 16 residents (Residents #14 and #23) reviewed for environments free from accident and hazards. 1. The facility failed to check a shower room prior to turning off the shower room lights and locking the door; Resident #23 was in the shower room and left alone in a dark with the door locked and fell. 2. The facility failed to ensure storage rooms containing equipment to draw blood for lab work, such as needles and syringes, were secured. This failure could place residents at risk for involuntary seclusion and injuries as well as injuries from syringe needles. An Immediate Jeopardy (IJ) was identified on 03/14/2024 at 08:05 PM. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure must 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. for 1 (Resident #20) of 21 residents reviewed in that: Resident #20 did not have a care plan for his urinary catheter or where the pacemaker was located. The failure could place residents at risk of not receiving care as ordered and needed.

Inspectors wroteBased on observations, 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 21 (Resident #20) reviewed in that: Resident #20 did not have an order for his colostomy, urostomy, urinary catheter, or his pacemaker. The failure could place residents at risk of not receiving care as needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, for 1 of 8 Residents (Resident #13) reviewed for nutritional status in that: The facility failed to initiate timely intervention to prevent weight loss when Resident #13 experienced continuous significant weight loss of -10.84% (13.8 pounds) between the dates 12/01/2023 and 01/04/2024. These failures could place residents who are dependent on staff for their nutrition and hydration at risk for nutritional deficit, weight loss, skin breakdown, and overall decline in quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents are free of any significant medication errors for 2 of 2 (#9, #47) residents reviewed in that: 1. Resident #9 was administered Midodrine (a blood pressure medication) 9 times in February and March 2024 above parameters when it should have been held. 2. Resident #47 was administered Midodrine more than 39 times (2/13/2024 to 3/9/2024) in February and March 2024 without parameters (orders from the physician to determine where to give the medication or not based upon the blood pressure). This failure could result in residents having risk of heart attacks, strokes, blood clots, and risk of hospitalizations.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations which involved abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately 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 3 of 16 Residents (Residents #1, #23, and #43) reviewed for reporting of alleged Abuse, Neglect, exploitation, and or mistreatment. 1. The facility failed to ensure staff reported to the Administrator and or the state agency Resident #43's alleged physical aggression towards Resident #1. 2. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to have evidence that all alleged violations of abuse, neglect, exploitation, or mistreatment were thoroughly investigated and prevented further potential abuse, neglect, exploitation, or mistreatment while the investigation was in progress, 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 3 of 16 residents (Residents #1, #23 and #43) reviewed for investigation to prevent further potential abuse, neglect, exploitation, or mistreatment. 1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles in locked compartments and permit only authorized personnel to have access to the keys for 1 of 8 resident rooms (Resident #41) reviewed for storage of drugs, in that: An over-the-counter dietary supplement was found on a nightstand in a resident's room. This failure could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observations, interviews and record reviews 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 18 (Resident #101) residents in that: LVN T did not use hand hygiene between cleaning Resident #101's plate/tray and touching an unknown resident's dessert plate. This could affect all residents that use plates from kitchen and could result in bacteria and cross contamination.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.