Wurzbach Nursing and Rehabilitation

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for residents for 4 of 5 residents (Resident #1, Resident #2, Resident #3, and Resident #5) reviewed for accidents and hazards. The facility failed to ensure Resident #1 did not have body wash/shampoo/conditioner in his bathroom. The facility failed to ensure Resident #2 did not have perineal/skin cleanser and shave cream in his bedroom and bathroom. The facility failed to ensure Resident #3 did not have mouthwash in her room. The facility failed to ensure Resident #5 did not have shampoo/body wash, peri-wash, and lotion in her room and peri-wash in her bathroom. This deficient practice could result in residents having diminished health and/or quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access for 1 of 4 residents (Resident #4) reviewed for medication storage. The facility failed to ensure Resident #4 did not have the medication Mupirocin in her room on the Memory Care Unit on 6/30/26. This failure could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained free of accidents and hazards for 3 residents (Resident #22, #49 and #39) of 24 residents reviewed for environmental hazards, in that: 1. Resident #22's wheelchair did not have a pad on the right arm rest which exposed a bare metal bar with holes where bolts would be attached. 2. Resident #49's wheelchair did not have a pad on the right arm rest which exposed a bare metal bar with holes where bolts would be attached. 3. Resident #39's headboard on his bed was detached and his foot board had veneering missing which exposed raw rough particle board. This failure could place residents at risk of skin tears due to wheelchairs and furniture in disrepair.

Inspectors wroteBased on observations, 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 (Resident #19) of 13 residents and 2 of 2 medication rooms (A-wing and C-wing medication room) reviewed for pharmacy services. 1. When LVN-G administered medication (Omeprazole delayed release 20 mg) to Resident #19 through gastrostomy tube (feeding tube inserted thought the belly that bring nutrition or medication directly to the stomach), LVN-G opened the medication, but the label of the medication said, Do not open or crush! 2. There was one box of suction catheter kit expired 06/07/2025 found inside A-wing medication room on 06/11/2025. 3. [...]

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 observed for kitchen sanitation. 1. The facility failed to ensure two trays of prepared and poured glasses of beverages in the refrigerator were dated. 2. The facility failed to ensure a try with six prepared bowls of cereal in the dry storage were dated. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

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 3 (Resident #25, #237, and #19) of 20 residents reviewed for infection control practices. 1. CNA D failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #25. 2. When CNA-I was providing peri care to Resident #237, CNA-I grabbed new and clean brief with old and dirty gloves after cleaning Resident #237's buttock area, put the new and clean brief under the resident, and closed it. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 24 (Resident #66) residents was treated with dignity during dining room observation. On 06/10/2025 at 12:45 pm, the Activity Director stood over Resident #66 when she fed her lunch. This failure could affect all residents in the facility and could result in low self-esteem.

Inspectors wroteBased on observations, interviews, 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 other residents for 1 of 20 residents (Resident #18) reviewed for accommodation of needs. The facility failed to ensure Resident #18's call light was within reach while she was positioned on her bed in her room. This failure could place residents at risk for delay in care and services, and increased risk of falls and injuries.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range, unless the resident's clinical condition demonstrated this was not possible or the resident preferences indicated otherwise for 1 of 5 Residents (Residents #16) whose records were reviewed for nutrition status maintenance. The facility failed measuring Resident #16's weight when the resident was re-admitted to the facility on [DATE], and the physician order said, Measuring weight upon admission/re-admission and every week for 4 weeks. These failures could affect residents at risk for losing weight and result in unplanned weight loss and a decline in the resident's overall health.

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 (Residents #27) of 3 reviewed for respiratory care. Resident #27's nebulizer mask was not covered in a plastic bag when it was not used on 06/10/2025. This failure could affect residents with oxygen therapy and could lead them to lack of care including possible infection by not following infection control.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 2 of 20 residents (Residents #46 and #238) reviewed for storage. 1. Resident #46's insulin Lantus Solos Flex Pen for diabetes had no open date, found inside B-wing nursing cart on 06/11/2025. 2. Resident #238's insulin Novolog Flex Pen for diabetes had no open date, found inside B-wing nursing cart on 06/11/2025. These failures could place residents at risk of having not therapeutic effects by using old insulins.

Inspectors wroteBased on observation, 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 #16) of 20 residents reviewed for medical records. The facility failed to ensure facility nurses documented Resident #16's mechanically altered diet correctly on 06/08/2025's Weekly Swallowing/Nutritional Status. This failure placed resident at risk for missed treatment and care which could result in decline in health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 5 of 27 (Cook K, Dietary Aide L, CNA M, CNA N, and LVN O) employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured [NAME] K, Dietary Aide L and CNA M received required trainings upon hire. The facility failed to implement and maintain a training program that ensured CNA N and LVN O received required trainings annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual communications training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure communication training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual rights of the resident training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure resident rights training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual abuse, neglect and exploitation training and dementia training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure abuse, neglect and exploitation training and dementia training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual QAPI training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure QAPI training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual infection control training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure infection control training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual ethics training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure abuse, neglect and exploitation training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure CNA received the required minimum 12 hours annual in-service 1 of 27 (CNA N) employees reviewed for training requirements was completed. The facility failed to provide the required 12 hours of annual training to CNA N. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to ensure annual behavioral health training for 2 of 27 (CNA N, and LVN O) employees reviewed for training requirements was completed. The facility failed to ensure abuse, neglect and exploitation training was provided CNA N and LVN O annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, are reported immediately but no later than 2 hours after the allegation is made, for 1 of 6 Residents (Resident #1), reviewed for freedom of abuse. The facility did not report to local law enforcement an allegation of sexual abuse involving Resident #1 by a CNA. This failure could result in law enforcement not investigating an allegation of sexual abuse and subjecting residents to other acts of sexual abuse, psychosocial and physical harm, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents for 2 of 4 residents (Resident #1 and #2) reviewed for accidents and supervision. 1. The facility failed to ensure Resident #1 did not elope from the facility without staff knowing on the evening of 09/24/2024. The noncompliance was identified as PNC . The IJ began on 9/24/2024 and ended on 9/25/2024. The facility had corrected the noncompliance before the survey began. 2. CNA A transferred Resident #2 from the bed to the resident's wheelchair without using a lift on 08/15/2024. It caused Resident #2's toenail to catch on the floor, injuring her nailbed and removing her whole toenail on her left great toe. The noncompliance was identified as PNC. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free of misappropriation of resident property and exploitation for 2 of 4 residents (Resident #5 and Resident #6) reviewed for misappropriation and exploitation. The facility failed to ensure Resident #5 and Resident #6's pain medications were secured and not lost. These failures could place residents who received pain medications at risk of decreased quality of life, misappropriation of property and distress.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, to other officials (including to the State Survey Agency in accordance with State law through established procedures) for 2 of 2 residents (Resident #3 and Resident #4) reviewed for Freedom from Abuse, Neglect, and Exploitation: The facility failed to report to the state survey agency Resident #4 hit Resident #3 on the head on 9/27/2024. This failure could place residents at risk for abuse, diminished quality of life, physical, and psychosocial harm.

Inspectors wroteBased on 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 5 residents (Resident #5 and #6) reviewed for pharmacy services. 1. The facility failed to ensure Resident #5's pain medications were acquired and dispensed per physician's orders. 2. The facility failed to ensure Resident #6's pain medications were acquired and dispensed per physician's orders. This failure could place residents at risk of not receiving their prescribed medications and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, dispensing, and administering of all drugs and biologicals to meet the needs of 3 (Resident #1, Resident #2, and Resident #3) of 3 residents reviewed for pharmacy services. 1. The facility failed to ensure MA A accurately documented on Resident #1's Controlled Substance Administration Record the administration time for scheduled pain medication, Tramadol HCl Oral Tablet 50mg. 2. The facility failed to ensure MA A accurately documented on Resident #2's Controlled Substance Administration Record the administration time for scheduled pain medication, Tramadol HCl Oral Tablet 50 mg. 3. [...]

Inspectors wroteBased on interview and record review, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that are complete, accurately documented, readily accessible, and systematically organized for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for reviewed for administration. 1. The facility failed to document wound care was provided for Resident #1 on five (5) occasions on Resident #1's September Treatment Administration Record (TAR). 2. The facility failed to document skin treatment was provided for Resident #2 on six (6) occasions on Resident #2's September TAR. 3. The facility failed to document wound care was provided for Resident #3 on thirty-four (34) occasions on Resident #3's September TAR. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident's physician when there was a significant change in resident's physical, mental, or psychosocial status for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to consult with Resident #1's physician and provide all necessary details, when Resident #1 complained of a worsening wound on 09/22/2024. This failure could place the resident at risk for delay in treatment and a decline in the resident's health and well-being due to the physician not being notified of changes in the resident's condition in a timely manner.

Inspectors wroteBased on interviews and record reviews the facility failed to immediately inform the resident and notify, consistent with his or her authority, the residents' representative(s) when there is a significant change in the resident's physical, mental, or psychosocial status and or a need to alter treatment significantly, for 1 of 3 residents (Resident #1) reviewed for being informed of their health status. The facility failed toensure they reported to Resident #1's Representative on 08/14/2024 of Resident #1's change of condition (episodic high blood pressure) to include new orders for anti-high blood pressure and anti-nausea / vomit medication. This failure could place residents at risk for harm by not reporting a residents health status and the opportunity for consent of care .

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #28) reviewed for medication administration. Resident #28 was provided a medication, Midodrine, outside of physician parameters. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, ensure all drugs and biologicals were stored properly in the medication cart for 1 (Station A) of 3 medication treatment carts observed for drug storage. The facility failed to ensure 5 insulin pens were dated when opened. This failure could result in harm due to resident received expired medications.

Inspectors wroteBased on interview and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 1 of 5 (CNA E) CNAs in that: CNA E did not have a current EMR/NAR check. This could place residents at risk of abuse, neglect, and exploitation.

Inspectors wroteBased on observation, 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 8 residents (Resident #56) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #56 had an unwitnessed fall a skin tear and a hematoma to her head. 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 record review and interview, the facility failed to thoroughly investigate all alleged violations of resident abuse, neglect, exploitation, or mistreatment for 1 of 6 (Resident #56) residents assessed for reporting allegations. The facility failed to thoroughly investigate an incident in which a resident was found on the floor of their room with a skin tear to the right forearm and a hematoma to the top of the resident's scalp. This deficient practice placed residents at risk of abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on interview and record review the facility failed to ensure, before a resident was transferred to a hospital or the resident went on therapeutic leave, provided written information to the resident or the resident representative that specified the duration of the bed-hold policy, if any, during which the resident was permitted to return and resume residence in the nursing facility for 1 of 1 residents (Residents #89) reviewed for transfers, in that: The facility did not provide Resident #89 with a written bed-hold policy when the resident was transferred out to the hospital. This failure could place residents at risk for not receiving notice of the facility's bed hold policy before being transferred and at risk for of being improperly discharged and placed in unsafe conditions.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident receives an accurate assessment for 1 of 9 (#77) that were reviewed in that: Resident #77 was discharged on 1/25/2024 and a discharge MDS was not completed. This could affect all residents and could result in residents' information not being accurate.

Inspectors wroteBased on interview and record review the facility failed to ensure when the facility anticipates discharge, a resident must have a discharge summary that includes, but is not limited to, a recapitulation of the resident's stay that includes, but is not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results, a final summary of the resident's status to include items in paragraph, at the time of the discharge that is available for release to authorized persons and agencies, with the consent of the resident or resident's representative; reconciliation of all pre-discharge medications with the resident's post-discharge medications (both prescribed and over the counter) for 1 of 3 (Resident #77) resident reviewed for discharge in that: Resident #77 was discharged on 1/25/2024 and a discharge summary was not completed. [...]

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, the residents' goals, and preferences for 1 of 20 residents reviewed for respiratory care. (Resident #240) The facility did not ensure Resident #240 had orders for the administration of oxygen. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on 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 8 (Resident #64) in that: Resident #64 was not administered her Tylenol and Senexon . This could affect all residents and could result in residents not administered medications can increase pain and constipation.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable, and sanitary environment to help prevent the development and transmission of diseases for 1 of 3 (Residents #82) and 1 of 1 (LVN B) staff reviewed for infection control. LVN B failed to change gloves after removing a soiled dressing and failed to wash her hands or use ABHR after glove change. LVN B failed to wear proper PPE. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to provide reasonable accommodation of resident needs and preferences for 3 (Resident #3, #6, and #8) of 54 residents who resided on A and B hall reviewed for call lights. In that: Resident #3 had no access to his call light which had been clipped to the privacy curtain at the foot of his bed. Resident # 6 had no access to her call light which was on the floor under the roommate's bed and on the floor next to her bed. Resident #8 had no access to her call light which was on the floor under the foot of her bed. This deficient practice could place residents not being able to use call lights for assistance in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated the preferences for 2 of 13 residents reviewed for food preferences and the accommodation of resident's meal choices (Resident #'s 5 and 7). The facility did not honor Resident #5's allergy to foods and continued to serve her foods she was allergic to. The facility did not honor Resident #7's food preferences and continued to serve him foods he asked not to receive. This failure could place residents who report likes/dislikes and allergies at risk for dissatisfaction, poor intake, weight loss, and/or allergic reaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 4 of 5 residents (Resident # 1, #2, #3, #4,) reviewed for infection control in that: 1. The facility failed to ensure LVN A, during the medication pass, performed hand hygiene after administering medications to Residents #1 and #2. 2. The facility failed to ensure LVN A, during the medication pass, sanitized the blood pressure cuff after taking Residents #1 and #2's blood pressures. 3. The facility failed to ensure LVN B, during the medication pass, sanitized the blood pressure cuff after taking Residents #3 and #4's blood pressures. These deficient practices could place residents at risk for cross contamination.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident(s) environment remained as free of accident hazards as is possible and each resident received adequate supervision and assistance devices to prevent accidents, for 2 of 9 residents (Resident #1 and Resident #6) reviewed for accident hazards and supervision, in that; 1. Resident #1 had one unauthorized, unchaperoned elopement event on [DATE]. 2. Resident #6 had one unauthorized, unchaperoned elopement event on [DATE]. The non compliance was identified as past noncompliance IJ(immediate Jepordy). The first non compliance began on [DATE] and ended on [DATE]. The second non compliance began on [DATE] and ended on [DATE]. The facility had corrected the non compliance before the survey began. This failure could place residents at risk for harm, injury, or death due to elopement.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to assure that all nursing staff had the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population for 1 of 5 residents (Resident #3) reviewed for continuity of nursing care, in that; The DON and LVN E failed to provide supervision and continuity of nursing care for Resident #3's infected left knee. Resident #3 was delayed by 2 days in receiving care for a red swollen infected knee. These failures placed Resident(s) at risk for harm by delayed care and increased infection.

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 1 of 5 residents (Resident #4) reviewed for injuries of unknown source, in that: The DON and LVN B did not report to the state agency and or investigate Resident #4's head injury of an unknown origin . This failure could place residents at risk for abuse.

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 3 secured courtyards (B wing courtyard) reviewed, in that: The facility failed to ensure that the B wing courtyard back door/fence was secured to prevent the public from coming into the facility and to prevent the residents from eloping. The non compliance was identified as past noncompliance. The noncompliance began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before the survey began. This deficient practice could place residents, staff, and the public at risk of exposure to potentially dangerous materials.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to provide basic life support, including CPR to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 (Resident #1) of 1 residents reviewed for CPR, in that; The facility failed to ensure Resident #1 received life saving measures including CPR (Cardiopulmonary Resuscitation) when he was found unresponsive on [DATE]. The non-compliance was identified as past non-compliance. The IJ began on [DATE] and ended on [DATE]. The facility had corrected the noncompliance before survey began. This failure could place residents at risk of not receiving life safe measures including CPR and could lead to death.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the rights of residents 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 other residents, for 1 of 5 residents reviewed (Resident #17) for accommodation of orthotic support devices, in that: The facility failed to report to Resident #17's physician's the inability to fulfill Resident #17's order for a back brace, ordered by a neurologist [a medical doctor who specializes in diagnosing and treating diseases of the brain, spinal cord, and nerves]. Resident #17 had a compression fracture of vertebra and kyphosis. Resident #17had spinal surgery and an order for a back brace from November 2022 that she did not receive. Resident revealed she was in [NAME] pain. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure residents had the right to and the facility had made prompt to resolve grievances the residents may have had, in accordance with identifying a Grievance Official who is responsible for overseeing the grievance process, receiving and tracking grievances through to their conclusions; leading any necessary investigations by the facility; issuing written grievance decisions to the resident; and coordinating with state and federal agencies as necessary in light of specific allegations; As necessary, taking immediate action to prevent further potential violations of any resident right while the alleged violation is being investigated; for 2 of 5 residents(Resident #6 and Resident #17) reviewed for grievances, in that: 1. [...]

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 and sanitary environment, and to help prevent the development and transmission of communicable disease and infections for 2 of 2 (Residents #12 and #67) observed for care in that: 1. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #12. 2. CNA A failed to remove her gloves and perform hand hygiene before moving from a contaminated-body site to a clean-body site during care for Resident #67. This failure can affect residents in the facility who received incontinent care and could result in spread of infections.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 2 of 5 Residents (Resident #15 and Resident #18) reviewed for the ability to call for staff, in that: Resident #15 and Resident #18 presented with their call light on the floor away from their reach. This failure could place residents at risk for injury and diminished self-esteem, due to the inability to call for assistance.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 1 of 46 (Resident #67) sampled residents was treated with dignity during dining room observation. CNA A prevented Resident #67 to move freely by locking his wheelchair after he was finished with his breakfast. This failure could affect all residents in the facility and could result in residents not being treated with dignity.

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 are 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 1 of 5 Residents (Resident #6) reviewed for injuries of unknown origin reporting, in that: Resident #6 was assessed with a large bruise from her chest to her under arm and continued to her back, which was not investigated and not reported to the state agency and Resident #6's Guardian as an injury of unknown origin. This failure could place Resident(s) at risk for harm by further exposure to injuries without proper investigation and reporting.

Inspectors wroteBased on interviews and record reviews the facility 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. The comprehensive care plan must describe the following, 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 (#47) residents in the secured memory care unit in that: Resident #47 did not have a care plan for care in the secure memory care unit. This could affect residents in the secure unit and could result in residents not provided care while in the memory care unit.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that a resident who has a prosthesis is provided care and assistance, consistent with professional standards of practice, the residents' goals and preferences, to wear and be able to use the prosthetic device for 1 of 5 (Resident #17) residents reviewed for orthotic devices, in that: Resident #17 needed a back brace as ordered by her neurosurgeon, and the facility failed to escalate their efforts to secure the back brace for Resident # 17. This failure could place residents at risk for health status decline without the support and therapeutic effects of prostheses devices.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide or obtain laboratory services only when ordered by a physician; physician assistant; nurse practitioner or clinical nurse specialist in accordance with State law, for 1 of 5 residents (Resident #238) reviewed for laboratory services, in that: Resident #238 was ordered a urinalysis which was not sent to the laboratory for 7 days. This failure placed residents at risk for health status decline related to denying the physician a prompt result from the ordered urinalysis.