Woodville Health and Rehabilitation Center

Inspectors wroteBased on interviews and record reviews, the facility failed to treat each resident with respect and dignity and provided care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 10 residents reviewed for resident rights. (Resident #1) The facility failed to treat Resident #1 with dignity and respect by LVN A denying his multiple requests to seek medical treatment at local ER on [DATE]. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with professional standards of practices, the medical records on each resident were completely documented for 2 of 7 residents reviewed for complete medical records. (Residents #1 and #2) * The facility did not have any documentation of Resident #1 having elopement behaviors prior to her placement on the secured unit. * The facility did not have orders for Residents #1 and #2 to reside on the secured unit. This failure could place residents at risk of restraint and isolation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 2 of 10 residents (Residents #13 and #34) reviewed for unnecessary medication. 1. The facility failed to monitor Resident #13 for side effects of the antianxiety medication, lorazepam (used to treat anxiety) routinely and PRN.2. The facility failed to ensure a stop date or reorder date was ordered for the PRN lorazepam for Resident #13. 3. The facility failed to ensure Resident #13 was monitored for side effects of the antipsychotic medication quetiapine fumarate (used to treat bipolar disorder).4. The facility failed to monitor Resident #34 for side effects of the antipsychotic medication Abilify (used to treat several mental health conditions). These failures could place residents at risk for adverse consequences and decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program for 1of 1 kitchens reviewed for effective pest control in that: Numerous flies were observed throughout the kitchen during the noon meal preparation time on 07/07/2025. This failure could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had a right to a clean and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 2 shower rooms and 1 of 15 residents reviewed for environmental concerns. The facility failed to ensure Hall 400's shower room did not have one shower chair soiled with a brown substance with grayish area surrounding below the seat. The facility failed to ensure Resident #26's wheelchair and wheelchair cushion did not have smears of food and food particles. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident in a nursing facility was screened for a mental disorder (MD) or intellectual disability (ID) prior to admission and that individuals identified with MD or ID were evaluated and receive care and services in the most integrated setting appropriate to their needs for 1 of 8 residents (Resident #1) reviewed for PASRR screenings. The facility failed to submit a new PL1 screening to TMHP (a group of contractors that administer Texas Medicaid on behalf of the Texas Health and Human Services Commission) dated 03/06/25, which indicated Resident #1 had positive evidence of mental illness. This failure could place residents at risk of not receiving specialized services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that the medication error rate was less than five percent or greater. The facility had a medication error rate of 7.79% based on 2 errors out of 26 opportunities, which involved 2 of 6 residents (Residents #6 and #49) and 2 of 3 staff observed during medication administration reviewed for medication error. 1. The facility failed to ensure LVN A administered Dorzolamide Solution 2% Ophthalmic (eye drops) per facility policy to Resident #49. 2. The facility failed to ensure LVN B did not administer Levothyroxine 75 MCG to Resident #6 on an empty stomach. These failures could place residents at risk of unwanted side effects and not receiving the therapeutic dosage of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 1 residents room reviewed for food safety (room [ROOM NUMBER]) in that: The refrigerator located in room [ROOM NUMBER] was not monitored for expiration/used by dates. This failure could place residents at risk for food illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain clinical records on each resident in accordance with accepted professional standards and practices that were complete and accurately documented for 2 of 3 residents on the secured unit reviewed for clinical records. (Resident #32 and #7) The facility did not have a physician order for placement on the Secured Unit and an Elopement Assessment upon admission to the Secured Unit for Resident #32. The facility did not have an Elopement Risk Assessment for change in condition, a physician order for placement on the Secured Unit, and a complete care plan for Resident #7. These failures could place residents on the Secured Unit at risk of being inappropriately place and staff not being aware of needs for 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 for2 of 4 residents reviewed for infection control. (Residents #102 and #252) The facility did not have appropriate signage indicating Resident #102 was on Droplet Isolation. The facility did not ensure staff implemented appropriate infection control measures while providing care for Resident #252. These failures could place residents, staff, and visitors at risk of exposure to Infectious diseases, decreased health, and/or hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 15 residents reviewed for resident assessments (Resident #6). The facility did not have a PASRR level 1 screening (PL1) for Resident #6 upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 3 residents reviewed for care plans on the Secured Unit. (Resident #10) The facility did not have an Elopement care plan for Resident #10. This failure could place residents on the Secured Unit at risk of not having individual needs met and not receive needed services.

Inspectors wroteBased on observation, interview, 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 1 of 15 residents reviewed for care plans. (Resident #43) The facility failed to ensure Resident #43's care plan accurately addressed his diagnosis of urinary tract infection (UTI) and administration of antibiotics. This failure could place residents at risk for staff not being aware of the resident needs and not receiving the care and services to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 13 residents reviewed for significant medication errors. (Resident #152) The facility did not continue to hold Resident #152's Eliquis following an outpatient minimal invasive procedure. This failure could place residents at risk of harm, impairment, or death from receiving a significant medication when it should have been held.

Inspectors wroteBased on observation, interview, and record review the facility failed to store food in accordance with professional standards for one of one kitchen reviewed food service safety. * There were unlabeled, undated, and unsealed containers of food items stored in the refrigerator and dry goods storage. * The facility failed to ensure the DM did not handle uncovered food plates with his bare hands. These failures could place residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on interview and record review, the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 2 of 15 residents reviewed for PASARR (Preadmission Screening and Resident Review). *The facility did not complete a new PASARR Level 1 Screening (a preliminary assessment) completed for all individuals prior to admission to a Medicaid-certified nursing facility to determine if a person has, or is suspected of having, a mental illness, intellectual disability or related condition) when Resident #4 was diagnosed with schizoaffective disorder (combination of schizophrenia (serious mental illness) and mood disorder) on 12/19/22. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 15 residents (Resident #7) reviewed for ROM (range of motion). The facility did not have a treatment in place for Resident #7's contractures of the left hand to prevent further decline in ROM. This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

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 11 residents (Resident #6) and in 2 of 2 medication carts (100/200 hall nurse cart and 300/400 hall medication aide cart) reviewed for pharmacy services. * Resident #6 had 2 sets of hold parameters for her verapamil (blood pressure medication). LVN C held Resident #6's verapamil without verifying which set of parameters were correct. * The facility had a medication error rate of 4%. * The facility did not dispose of expired medications from the 100/200 hall nurse cart and 300/400 hall medication aide cart. [...]

Inspectors wroteBased on observation and interview the facility failed to promote care for residents in a manner and in an environment that maintains or enhances each resident's dignity 1 of 4 residents reviewed for resident rights. (Resident #145) * The facility did not serve Resident #145's lunch tray when they served his tablemate's, and he was served his dessert before the lunch meal tray. This failure could place residents at risk of poor self-esteem and decreased self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate MDS was completed for 1 of 18 residents reviewed for MDS assessment accuracy. (Resident #18) * The facility incorrectly coded Resident #18's antiplatelet as an anticoagulant on his MDS. This failure could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding by 1 of 2 nurses administering medications through a percutaneous endoscopic gastrostomy (PEG) tube. (LVN A) * LVN A did not check placement of Resident #32's PEG tube (a tube going into the stomach through the abdomen to administer medications and liquid nutrition) placement prior to flushing with water and administering medications. This failure could place residents with PEG tubes at risk for abdominal pain, vomiting, or hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain infection control prevention and practices for point of care equipment by 2 of 9 staff reviewed for infection control. ( LVN D, and LVN E) * The facility failed to ensure LVN D and LVN E cleaned and disinfected glucometers appropriately after resident use. These failures could place residents at risk of infections or diseases.