Sabine Retirement and Rehab Center

Based on observation, record review, and interview the facility failed to protect a resident's right to privacy and confidentiality of personal and medical records by failing to ensure 1 (Resident #4) of 4 sampled resident's name, medical appointment and diagnosis were not visible in a public area within the facility. Findings:Review of a facility policy titled Resident Rights, with no review date read in part.8. Privacy and confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal medical records.b. The resident has a right to secure and confidential personal and medical records.Review of Resident #4's medical record revealed an admit date of 09/24/20215, with diagnoses that included in part.Malignant Neoplasm of Prostate, Vascular Dementia, and Other Sequelae Following Unspecified Cerebrovascular Disease.Review of a Radiation Oncology Consultation note date 06/01/2026 read in part.Chief Complaint: I am here to discuss radiation for my Prostate Cancer. Observation on 06/16/2026 at 10:20 a.m. of nurses' station located at the front…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles. This deficient practice had the potential to affect all 106 residents who resided in the facility. The facility failed to:Ensure expired and unlabeled medications were not available for administration to residents in 1 (Med Room B) of 2 medication rooms; andEnsure expired medications and supplies were not available for administration to residents in 2 (Med Cart B and Med Cart E) of 5 medication carts. Findings:Review of a facility policy on 01/13/2026 at 10:40 a.m. titled, Pharmacy Services with a revision date of 01/05/2025 revealed the following in part .It is the policy of this facility to ensure that pharmaceutical services, whether employed by the facility or under an agreement, are provided to meet the needs of each resident, are consistent with state and federal requirements, and reflect current standards of practice. Review of an undated facility policy on 01/13/2026 at 10:10 a.m. titled,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to make a prompt effort to resolve grievances filed by a resident's representative, for 1 (Resident #3) of 27 sampled residents.Findings: Review of the facility's policy titled Grievances/Complaints, with no review date, revealed in part.1. Any resident, his or her representative (sponsor), family member, or appointed advocate may file a grievance or complaint to the facility.3. Grievances and/or complaints may be submitted orally or in writing and may be filed anonymously. 4. Upon receipt of a grievance and/or complaint, the grievance official will ensure prompt investigation and resolution of the allegations; and ensure that immediate action is taken if necessary to prevent further potential violations of any resident rights while the allegation is under investigation.5. The administrator will review the grievance.6. The administrator will review the findings with the person investigating the complaint to determine what corrective actions, if any, need…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure an allegation of resident to resident physical abuse was reported to the State Survey Agency immediately, but not later than 2 hours after the resident to resident physical abuse was discovered for Resident #55. Total sample size 27. Findings:Review of the facility's undated policy titled Abuse Prevention and Investigation read in part.Residents have the right to be free from verbal, sexual, physical, and mental abuse. Policy Interpretation and Implementation:1. The facility defines abuse as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain, or mental anguish. Examples of physical abuse include: hitting, slapping, pinching, and kicking. 16. Reporting:a. All alleged violations of abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property will be reported immediately, but no later than 2 hours after the allegation is made if the alleged violation involves abuse. Resident # 55 Review…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

F656Based on interview and record review the facility failed to develop/implement a Person-Centered Care plan for 1 (Resident #78) of 27 sampled residents to include a Percutaneous Endoscopic Gastrostomy (PEG tube) and appropriate nursing interventions.Findings: Review of Resident #78's medical record revealed an admit date of 10/07/2025 with diagnoses that included in part.Hemiplegia and Hemiparesis following Cerebral Infarction Affecting Left Non-Dominant Side, Mild Protein-Calorie Malnutrition, Type II Diabetes Mellitus, Dysphagia following Cerebral Infarction, and Cognitive Communication Deficit.Review of Resident #78's Significant Change MDS with and ARD of 11/21/2025 revealed a BIMS score of 4 which indicated severe cognitive impairment. The MDS revealed Resident #1 was dependent for all ADL's. The MDS revealed Resident #78 was coded for holding food in mouth/cheeks or residual food in mouth after meals.Observation on 01/12/2026 at 9:50 a.m. revealed Resident #78 lying in bed. Enteral feeding and water infusing via pump.Review of Resident #78's 01/2026 physician orders…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure that each resident who were unable to carry out ADL's (Activities of Daily Living) received necessary services to maintain good grooming and personal hygiene. The facility failed to provide a shower/bath to dependent residents for 1 (Resident #3) of 27 sampled resident.Findings:Review of the facility's policy titled Activities of Daily Living (ADLs) with no review date, revealed in part.Policy: The facility will, based on the resident's comprehensive assessment and consistent with the resident's needs and choices, ensure a resident's abilities in ADL's do not deteriorate unless deterioration is unavoidable.Care and services will be provided for the following activities of daily living:1. Bathing, dressing, grooming and oral care.Policy Explanation and Compliance Guidelines:3. A resident who is unable to carry out activities of daily living will receive the necessary services to maintain good nutrition, grooming, and personal and oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to provide pharmaceutical services to ensure the accurate acquiring and administration of a prescribed medication (Amiodarone) to meet the needs of Resident #37. Total Sample size 27. Findings:Review of the facility's undated policy titled Medications-Administering read in part.Medications shall be administered in a safe and timely manner, and as prescribed. Review of Resident #37 's medical record revealed an admit date of 06/27/2025 with diagnoses that included in part: Chronic Atrial Fibrillation, Chronic Combined Systolic and Diastolic Heart Failure, Hyperlipidemia, Hypertension, Atherosclerotic Heart Disease of Native Coronary Artery without Angina Pectoris, Hypertensive Heart Disease. Review of Resident #37's Minimum Data Set (MDS) with an ARD of 10/30/2025 revealed Resident #37 had a BIMS score of 13, indicating intact cognition. Resident #37 was independent/ required minimal assistance with activities of daily living. Review of Resident #37's Physician Orders for January 2026 revealed in part. Amiodarone HCl oral…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview the facility failed to ensure garbage was disposed properly. Findings: Review of the non-dated facility policy titled Trash read in part .All waste must be placed in sealed containers .All garbage and trash will be placed in a dumpster in a convenient area near the facility . Observation on 10/07/2024 at 8:54 a.m. accompanied by S2 Dietary Manager revealed 5 large trash bags on the ground next to the facility dumpsters. Interview on 10/07/2024 at the time of the observations with S2 Dietary Manager, confirmed that the trash bags should have been placed in the dumpsters and not left on the ground.

Based on record review and interview, the facility failed to ensure the Nurse Practitioner documented a clinical rationale for a denial of a dose reduction for 1 (#56) of 5 (#2, #23, #28, #56, #57) residents reviewed for unnecessary medications. The facility failed to ensure the Nurse Practitioner documented a clinical rationale for not reducing psychoactive medications recommended for gradual dose reduction. Findings: Review of Resident #56's clinical record revealed an admission date of 06/15/2022 with a Re-entry date of 05/25/2023 with diagnosis that included Alzheimer's Disease, Paranoid Schizophrenia, Generalized Anxiety Disorder, Unspecified Dementia Unspecified Severity with Other Behavioral Disturbance, Insomnia, Major Depressive Disorder, Extrapyramidal and Movement Disorder, Schizoaffective Disorder Bipolar Type Review of Resident #56's Quarterly MDS with an ARD of 12/11/2024 revealed a BIMS score of 99, severe cognitive impairment. Review of Resident #56's Physician's Orders for October 2024 revealed the following: Trazodone 75mg at Bedtime Seroquel 100mg every morning…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation and interview, the facility failed to store food in accordance with professional standards for food service safety by failing to ensure food items were stored in the refrigerator after opening. Findings: Review of the non-dated facility policy titled Storage: Refrigerator read in part . Keep all perishable foods below 41 degrees F (7 degrees C). Observation of the dry storage area in the kitchen on 10/07/2024 at 8:40 a.m. accompanied by S2 Dietary Manager revealed an open bottle of lemon juice with a hand written date of 09/15/2024, and a non-dated open bottle of teriyaki sauce. Review of the manufacture labels on the lemon juice and teriyaki sauce indicated to Refrigerate after opening. Interview on 10/07/2024 at the time of the observations with S2 Dietary Manager, confirmed that the lemon juice and teriyaki sauce should have been refrigerated after it was opened.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure the assessment accurately reflected the residents' status during the observation period for 1 (Resident #9) of 1 sampled resident for hospice. Findings: Review of Resident #9's clinical record revealed Resident #9 was admitted to the facility on [DATE]. Resident #9 had diagnoses that included Hypertensive Heart Disease with Heart Failure, Adult Failure to Thrive, Mild Protein Calorie Malnutrition, Muscle Wasting and Atrophy, and Difficulty Walking. Review of Resident #9's Physician Orders revealed in part . 06/01/2023 Admit to hospice. Review of Resident #9's Significant Change MDS Assessment with an ARD 06/09/2023 indicated Resident #9 was receiving dialysis while a resident. Review of the Assessment did not reveal Resident #9 was receiving hospice services. Review of Resident #9's May 2023 and June 2023 Physician orders revealed no orders for dialysis. Interview on 09/11/2023 at 2:55 p.m. with Resident #9 revealed she was not on dialysis.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review the facility failed to ensure each resident's assessment will be coordinated by and certified as complete by a registered nurse for 1 (#64) of 1 resident sampled for MDS record over 120 days old. The facility failed to ensure Resident #64's MDS Correction Request was signed by a registered nurse. Findings: Review of an MDS assessment transmission report revealed Resident #64's 05/05/2023 Significant Change Assessment had been attested on [DATE]. Review of the Resident #64's MDS Correction Request form dated 08/17/2023 revealed a modification had been requested due to an item coding error. Review also revealed the signature box designated as RN Assessment Coordinator Attestation of Completion, had been electronically signed by S4 LPN/MDS Coordinator. Interview on 09/12/2023 at 4:00 p.m. with S2 DON and S4 LPN/MDS Coordinator confirmed the correction request/attestation of completion for Resident #64's Significant Change Assessment with target date 05/05/2023 had not been…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 (Resident #231) of 1 (Resident #231) residents sampled for pain. The facility failed to ensure Resident #231 who displayed verbal and/or nonverbal indicators of pain received the ordered interventions to alleviate severe pain. Findings: Review of the facility policy titled, Pain Management revealed in part Optimum and effective pain management is only successful through a systematic and total team effort. Continual monitoring, assessment and evaluation, resident education and utilization of scheduled medications and modalities is crucial to the success of each resident's pain management plan. Review of Resident #231's clinical record revealed an admit date of 09/04/2021. Review of the clinical record also revealed Resident #231 had diagnoses that included Dorsalgia, Osteoarthritis, Polyneuropathy, Spinal Stenosis, and Pain.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, record review and interview the facility failed to provide pharmaceutical services to ensure procedures that assure accurate acquiring, receiving, dispensing and administration of medications to meet the needs of each resident. The facility failed to provide medications and/or biologicals to meet the needs of residents for 1 (Resident #231) of 1 residents sampled. Findings: Review of the facility's policy titled, Orders-Medication revealed in part . Drugs and biologicals that are required to be refilled must be reordered from the issuing pharmacy not less than (3) days prior to the last dosage being administered to ensure that refills are readily available. Interview on 09/11/2023 at 12:44 p.m. with Resident #231 revealed he was not feeling well. Resident #231 stated his back was hurting and grimaced while motioning to his lower back. Resident #231 stated he normally took medication for his back pain every morning but had not taken any this morning because the nurse told him he was out of medicine. Interview on 09/11/2023 at 12:21 p.m. with S3 LPN revealed…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.