Llano Nursing and Rehabilitation Center

In the surveyor’s words

From the most serious findings on record at Llano Nursing and Rehabilitation Center, in the surveyor’s own words.

• Immediate jeopardy, patternF600Dec 15, 2023

  Based on observation, interview, and record review, the facility failed to ensure residents were free from abuse and neglect for 2 of 16 residents (Residents #1 and #2) reviewed for abuse/neglect. The facility failed to take sufficient protective measures after Resident #1 made verbal threats to other residents and was involved in multiple physical altercations with other residents. The facility failed to train staff in resident -to-resident altercations and failed to update Resident #1's care plans to include interventions for behaviors and resident altercations. An Immediate Jeopardy (IJ) was identified on 12/14/23. The IJ template was provided to the facility on [DATE] at 6:21 pm. […]

• Immediate jeopardy, patternF656Dec 15, 2023

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 16 residents (Residents #1 and #3) reviewed for care plans. Resident #1 and Resident #3 did not have completed comprehensive care plans for resident-to-resident behaviors and resident-to-resident altercations. An Immediate Jeopardy (IJ) was identified on 12/14/23. The IJ template was provided to the facility on [DATE] at 6:21 pm. […]

• Actual harm, isolatedF760Aug 16, 2023

  Based on observation, interview, and record review, the facility failed to ensure the that its residents are free of any significant medication errors for 1 (Resident #1) of 5 residents reviewed for pharmaceutical services. The facility failed to provide pharmaceutical services for Resident #1 to include testing of her blood sugars and administration of insulin before meals as prescribed by her physician; the failure resulted in Resident #1 being found with low BS and unresponsive which required Resident #1 to be sent to the hospital 2 days in a row. This failure could place all residents at risk for not receiving the therapeutic effects from prescribed medications. […]

• Actual harm, isolatedF690Jun 28, 2023

  Based on observation, interview and record review, the facility failed to ensure all licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for one (Resident #27) of two residents reviewed for catheter care. LVN A inserted a foley catheter into Resident #27 urethra instead of re-inserting in his suprapubic stoma site and caused trauma and bleeding to the urethral region. This failure caused trauma and bleeding to the urethral region of Resident #27 and has the potential to affect all residents with catheters. […]

• Actual harm, isolatedF605Apr 28, 2022

  Based on observation, interview, and record review, the facility failed to ensure the right to be free from chemical restraint was provided for one (Resident #10) of five residents reviewed for chemical restraints, in that: The facility failed to attempt other interventions before administering [MEDICATION(S)] (anti-anxiety medication) to Resident #10 when he was yelling out. Resident #10 had physician's orders [MEDICAL RECORD OR PHYSICIAN ORDER] . Resident #10 did not have an appropriate diagnosis [MEDICAL RECORD OR PHYSICIAN ORDER] . This deficient practice placed residents at risk of being chemically restrained, sedation, and an altered mental status. […]