Will-O-Bell

Inspectors wroteBased on observation, interview and record review, the facility failed to conduct a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 6 residents (Resident #39) reviewed for comprehensive assessments. The facility failed to complete an accurate comprehensive assessment for Resident #39. This failure could place residents at risk of not having their care and treatment needs assessed to ensure necessary care and services were provided.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 1 (Resident #39) of 6 residents reviewed for quality of care. The facility failed to ensure Resident #39 had her gauze roll placed inside her left hand on 05/13/26 as directed by physician orders. These failures could place residents at risk of not receiving necessary medical care, pain, injury, infection, and hospitalization.

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 5 residents (Resident #3) reviewed for infection control. Resident #3 had a Stage 3 Pressure Ulcer to the Left buttock and the facility failed to place him on Enhanced Barrier Precautions. This deficient practice could increase the risk of the spread of infection to other residents. [...]

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 diseases and infections for 1 of 6 residents (Resident #1) reviewed for infection control. CNA A failed to properly dispose of Resident #1's soiled brief after incontinent are. CNA A failed to change gloves and perform hand hygiene after handling soiled brief. This failure could place residents at risk for infection and hospitalization.

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure drugs and biological's were stored under proper temperature in the Front Medication Room and the Back Medication Room reviewed for medication storage. The facility's failures could place residents receiving medication at risk for lack of drug efficacy.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation in that: - Food items were not labeled and/or dated. - Moldy and rotten food was present during inspection of the walk-in refrigerator. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting for one of one resident reviewed. The facility failed to submit a NFSS form request by the specific deadline for Resident #2 for a pressure reducing mattress and a motorized wheelchair. This failure could place residents at risk of not receiving or benefiting from specialized equipment they may require.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASARR for 1 of 2 residents (Residents #38) reviewed for PASARR Level 1 screenings. The facility failed to notify the local authority of the PASARR I screen for Residents #38. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for two (Resident #1 and Resident #2) of four residents reviewed for quality of care. The facility failed to: - Ensure Resident #1 was not sitting in his bed with linens covered in feces and his pants saturated with urine. The staff failed to complete accurate skin assessments to be able to provide appropriate treatment to MASD on his buttocks. - Ensure Resident #2 was getting barrier cream applied to a rash on her buttocks and failed to complete accurate skin assessments. [...]

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 two (Resident #1 and Resident #2) of four residents reviewed for medications. The facility failed to ensure Resident #1 was discharged home without two of Resident #2's medications (Trazadone and Tegretol). This deficiency put residents at risk of consuming unprescribed medications, harm, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 3 of 5 residents (Resident #7, #46, and #13) reviewed for indwelling urinary catheter care, in that: 1. Resident #7's indwelling urinary catheter drainage bag was on the floor. 2. Resident #46's indwelling urinary catheter drainage bag was on the floor. 3. Resident #13's indwelling urinary catheter drainage bag was on the floor. These failures could place the residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections.

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 service for 4 of 5 of the food and nutrition service staff reviewed for competency training in that: The facility did not ensure the DM, [NAME] W, [NAME] X, DA Y or DA Z had current food handlers training. The DM's food handler's certificate had an expiration date of 10/12/2023 with a start date of 05/21/2007. Cook W's food handler's certificate had an expiration date of 10/13/2023 with at start date of 06/17/2013. Cook X's food handler's certificate had an expiration date of 10/14/2023 with a start date of 08/17/2007. DA Z's food handler's certificate had an expiration date of 10/15/2023 with a date of 10/27/2008. [...]

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 areas in that: There were items in the kitchen that were not dated, not labeled with a date, not labeled with a name, ingredients or contents of packaging, and damaged kitchen spatulas. In addition there were only unpasteurized eggs in the kitchen that had been reportedly served with runny middles to residents. A cook failed to ensure eggs served soft fried with runny middle were pasteurized for 2 residents. These failures 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 diseases and infections for 3 of 8 residents (Resident #3, #30 and #57) reviewed for infection control practices, in that: 1. LVN D did not utilize appropriate hand hygiene during the medication pass to Resident #3 2. Med Aide T did not sanitize the blood pressure cuff used between Resident #30 and Resident #57 These failures could place residents at risk of infection, transmission of communicable diseases and a decline in health.

Inspectors wroteBased on observation and interview the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 4 Halls (Hall #2 and Hall #3) reviewed for environment in that: 1. The bedroom door to Resident room [ROOM NUMBER] on Hall #2 had splintered edges and had several pieces of wood missing and the bedroom door to Resident room [ROOM NUMBER] on Hall #2 had splintered edges and was partially covered in black duct tape. 2. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and had several pieces of wood missing. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and had several pieces of wood missing. The bedroom door to Resident room [ROOM NUMBER] on Hall #3 had splintered edges and was partially covered in black duct tape. [...]

Inspectors wroteBased on interview and record review, the facility failed to include effective communications as mandatory training for 14 of 14 employees (CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD). The facility failed to provide CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review, the facility failed to provide required education on the rights of the resident and the responsibilities of a facility to properly care for its residents for 7 of 14 employees (CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R and AD). The facility failed to ensure education on the rights of the resident and the responsibilities of a facility to properly care for its residents was provided to CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R and AD. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview, and record review, the facility failed to provide resident abuse prevention training to 4 of 18 staff reviewed including CNA K, CNA L, CNA O, and CNA Q. The facility failed to ensure that 4 of 18 staff reviewed had completed their mandatory abuse annual training. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program for 14 of 14 employees (CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD). The facility failed to ensure that quality assurance and performance improvement training was provided to CNA A, LVN B, LVN D, CNA K, CNA L, CNA M, MA N, CNA O, CNA P, CNA Q, LVN R, LVN S, FSS, and AD. This deficient practice could place residents at risk for not receiving safe and appropriate care by adequately informed staff regarding goals for care as identified by the QAPI committee and could result in a decline in health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to provide the mandatory training on standards, policies, and procedures for an infection prevention and control program for 9 of 14 staff (CNA A, LVN B, LVN D, CNA K, CNA L, MA N, CNA O, LVN S and AD) reviewed for training, in that: The facility failed to ensure infection prevention and control training was provided to CNA A, LVN B, LVN D, CNA K, CNA L, MA N, CNA O, LVN S and AD. This failure could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on interview and record review the facility failed to communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for 8 of 14 employees (CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R, LVN S and AD) reviewed for training, in that: The facility failed to ensure that compliance and ethics training was provided to CNA A, LVN B, CNA L, CNA O, CNA Q, LVN R, LVN S and AD. This failure could place residents at risk for improper care due to a lack of training.

Inspectors wroteBased on interview and record review, the facility failed to maintain the required minimum of 12 hours annual in-service records for 6 out of 7 CNAs employed for longer than one year reviewed for training (CNA K, CNA L, MA N, CNA O, CNA P and CNA Q). The facility failed to provide CNA K, CNA L, CNA M, MA N, CNA O, CNA P and CNA Q with 12 hours of in-service training per year. This failure could place residents at risk of being care for by untrained staff.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 10 residents (Resident #35) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #36 was inappropriately touching Resident #35. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on observation, interviews, and record review 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, the resident's goals, and preferences for 1 of 3 residents (Resident #17) reviewed for oxygen therapy in that: Resident #17's oxygen concentrator filter was covered in a thick white substance. This failure could affect residents who received respiratory therapy and put them at risk for inadequate or inappropriate amounts of oxygen delivery.

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 2 of 2 Residents (Resident #3 and #31) reviewed for medication administration in that: LVN D administered insulin to Residents #3 and #31 without priming the insulin pen prior to injection. These deficient practices could affect residents who received medication and place them at risk of not receiving the appropriate amount of medication and could result in an adverse reaction or a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 5 medication carts, (Treatment Cart), and in 1 of 6 resident rooms ( Resident #27's room) in that: 1. The facility failed to ensure the Treatment Cart was not left unattended and unlocked. 2. The facility failed to ensure a container of refresh eyedrops and an albuterol inhaler were stored properly in the facility. This deficient practice could affect residents who receive medications for treatments and could result in less potent or an adverse effects and drug diversion.

Inspectors wroteBased on interview and record review, the facility nursing staff failed to immediately notify the physician of a significant change in the resident's physical status for 1 of 2 residents reviewed for an unknown injury (Resident #2) LVN B and RN A failed to immediately notify Residents' Physician when a large bruise was discovered on his ankle, which was discovered to be a fracture. This failure may have resulted in Resident #2 experiencing pain from a fracture for 4-5 days.

Inspectors wroteBased on interview and record review, the facility staff failed to report to the administrator and/or designee, physician, and failed to investigate an injury of unknown source for 1 of 2 (Resident #2) reviewed for incident reporting. LVN B and RN A failed to reported an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment.

Inspectors wroteBased on interview and record review, facility staff failed to immediately, or within 2 hours, report injuries of unknown source to the administrator and/or designee and to other officials for 1 of 2 residents reviewed for an injury of unknown origins (Resident #2) LVN B and RN A did not report an injury of unknown origins on Resident #2 to the Nurse Practitioner or Doctor, to receive orders of care. This failure could place residents at risk of a delay in needed treatment.