Avir at Adams

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 for 1 (MC #1) of 1 MC reviewed for medication storage. The facility failed to ensure that MC #1 was secured while staff were not present. This failure could place residents at risk of getting access to medication that do not belong to them, resulting in potential harm from ingesting.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an effective pest control program so that the facility was free from pests for 1 of 1 kitchen rooms and 3 (Resident #2, Resident #4, and Resident #5) of 10 Resident rooms reviewed for environment. The facility failed to ensure the kitchen and dining room was free of cockroaches. The facility failed to ensure Resident #2, Resident #4, and Resident #5's room were free of cockroaches. These failures could place residents at risk for insect borne illness, not having a home free of pests and a comfortable environment in which to live.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident and resident's representative(s) of the discharge, reasons for the move, and right to appeal in writing and in a language and manner they understand and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 (Resident #1) of 5 residents reviewed for discharge planning. The facility failed to notify Resident #1's RP of Resident #1's discharge, reasons for the move, and right to appeal in writing, in a language and manner they understand, and at least 30 days before Resident #1 was discharged from the facility on 06/10/2026 in a facility-initiated discharge to another skilled nursing facility. The facility failed to send a copy of the notice to the facility's Ombudsman before Resident #1 was discharged from the facility on 06/10/2026. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 3 (Res#3, Res#4, and Res#5) of 3 residents reviewed. The facility failed to take residents who smoked out on a scheduled smoke break timely at 10:30 A.M. This failure could result in significant physical, emotional, and behavioral disruptions.

Inspectors wroteBased on observation, interview, and record review the facility failed to update two residents care plans (Res#1 and Res#2) of 7 residents reviewed to reflect interventions in place because of an incident that happened between them. The facility failed to update Res#1's and Res#2's care plans to reflect interventions in place because of an incident that happened on 05/03/26 at 6:26 PM. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on interviews and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1(Resident #1) of 6 residents reviewed for resident's rights. The facility failed to provide peri care in a timely matter for Resident #1 thus causing her to be left sitting in a soiled brief for over four hours. This failure could place residents at risk for decreased quality of life, decreased self-esteem and diminished dignity, leaving the residents feeling helpless, sad and hopeless.

Inspectors wroteBased on interviews and record reviews, the facility failed to protect the resident's(s') right to be free from abuse, neglect, misappropriation of property, and exploitation for 2 of 6 residents (R#1 and R#2). The facility failed to ensure R#1 was not sexually assaulted by R#2 on 12/27/25. An IJ was identified on 12/31/25. The IJ template was provided to the facility on [DATE] at 9:04 p.m. While the IJ was removed on 01/02/26, the facility remained out of compliance at a scope of isolated and a severity level of no actual harm with the potential for more than minimal harm that is not immediate jeopardy because of the facility's need to evaluate the effectiveness of their corrective systems. This failure could place residents at risk of further abuse, neglect, harm, injury, or death.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse, neglect, , investigate any such allegations, and ensure reporting of crimes occurring in federally-funded long-term care facilities for 1 of 6 residents (R#1). The facility failed to implement written policies and procedures in response to the sexual assault of R#1 in that R#1 was not offered emergency transportation services after the abuse incident with R#2 occurred on 12/27/25. An IJ was identified on 01/02/26. The IJ template was provided to the facility on [DATE] at 1:24 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that 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 to the administrator of the facility and to other officials for 1 of 6 residents (R#1). The facility failed to report R#1's and R#2's incident to the SSA and law enforcement within 2 hours after the abuse was observed. This failure could place residents at risk of continued abuse, neglect, harm, injury, or death.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, clean, comfortable, and homelike environment for 2 residents (Resident #1 and Resident #2) of 28 residents observed for a clean environment. The facility failed to ensure Resident #1 and Resident #2 had a homelike environment . These deficient practices could place residents at risk of a decreased quality of life.

Inspectors wroteBased on interview, observation, and record review, the facility failed , to provide an ongoing activities program to support residents in their choice of activities, both facility sponsored group and individual activities, and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for two of five residents ( Resident # 10 and Resident # 59 ) reviewed for activities. The facility failed to provide Resident # 10 in room activities during the months of April, May, and June of 2025. The facility failed to provide Resident # 59 in room activities twice per week during the months of April, May, and June 2025. This failure could place residents at risk for boredom, depression, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing and prevent infection for one (Resident #7) of two residents reviewed for pressure ulcers. 1. The facility failed to ensure that dressing changes were completed for Resident #7's pressure ulcer on 06/11/2025, 06/13/2025, and 06/16/2025. This failure could place residents with pressure ulcers at risk for infection, pain, and worsening of the wound.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that licensed nurses have the specific competencies and skill sets necessary to care for residents' needs for 4 (ADON, RN, LVN M, and LVN J) of 5 staff reviewed for nephrostomy care for Resident #21. The staff were not aware that the nephrostomy policy for the facility indicated that Resident #21 should have sterile dressing changes per the facility policy. This failure could potentially affect the residents by placing them at risk for infection and deterioration of the stoma site due to staff who lack the appropriate skills and competencies to minimize infections.

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 4 medication carts (MA B's Medication Cart #1 and Medication Cart #2) and 4 of 6 residents (Resident #5, Resident #7, Resident #10, and Resident #19) reviewed for pharmacy services. 1. The facility failed to ensure MA B accurately reconciled Resident #5's narcotic medication log for Medication Cart #1 when she administered Resident #5's tramadol (controlled medication used for pain) 1 tablet two doses and Codeine/Acetaminophen (controlled medication used for pain) 1 tablets two doses on 6/18/25. 2. [...]

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to prepare, distribute, and serve food in accordance with professional standards for food service safety. 1. The facility failed to maintain proper kitchen sanitation when the [NAME] did not follow proper hand hygiene protocols. 2. The facility failed to ensure residents were safe from potentially contaminated food when staff did not sanitize their hands between giving residents food. The deficient practice could place residents who were served from the kitchen at risk for health complications and foodborne illnesses. Findings Include: 1. Observation on 6/18/2025, at 9:30 AM, revealed that the Cook, after donning sanitized gloves, continued to prepare pureed noodles. While still wearing the same pair of gloves, she used three different kitchen utensils, a spatula, a serving spoon, and a whisk. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident medical records for two of six residents reviewed for wound care documentation (Resident #7 and Resident #21) were complete and accurately documented. 1. The facility failed to ensure that documentation of dressing changes provided to Resident #7 was accurate and completed on 06/09/2025, 06/11/2025, 06/13/2025, and 06/16/2025. 2. The facility failed to ensure that documentation of dressing changes provided to Resident #21 was accurate and completed on 06/18/2025 and 06/19/2025. This deficient practice could put the resident at risk of having inaccurate medical records and not receiving the ordered treatments and care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility reviewed for pests. 1. The facility failed to ensure the facility was free of gnats, and 2 roaches throughout the facility including resident rooms and resident restrooms 2. The facility failed to ensure the facility was free of bedbugs for Resident # 9. These deficient practices placed residents at risk of exposure to pests, diseases, infections, and diminished quality of life.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure the resident's right to secure and confidential personal and medical records for one (unknown resident) of 28 residents . The facility failed to ensure the privacy of the unknown resident by not locking the laptop screen, so the resident's information could not be seen by someone walking by. This failure put residents at risk for confidential health information exposure, psychosocial harm and decreased quality of life.

Inspectors wroteBased on interviews, and record review the facility failed to ensure the resident assessments accurately reflected the resident's status for 2 (Resident # 10 and Resident #7) of 8 residents reviewed for accuracy of assessments. 1. The facility failed to ensure Resident #10's Significant Change MDS assessment, dated 12/31/2024, completed Resident #10's preferences for customary routine and activities. 2. The facility failed to ensure that Resident #7's Significant Change in Status MDS assessment on 05/21/2025 accurately reflected that she had an unhealed pressure ulcer at the time of the assessment. This deficient practice could have placed the residents at risk for inadequate care and diminish quality of life due to inaccurate assessments.

Inspectors wroteBased on observations, interview and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for two of eight residents (Resident# 46, and Resident #59) reviewed for ADL care. The facility failed to ensure Resident #46's and Resident # 59's nails were cleaned, and did not have any rough edges. These failures could place residents at risk of not receiving services or care, diminished quality of life, and decreased self-esteem.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive care plan for one (Resident #21) of one resident reviewed for nephrostomy care. The facility failed to ensure dressing changes were done for Resident #21's surgical sites on 06/18/2025 and 06/19/2025 and completed per the physician orders and with sterile technique per the facility policy. This failure puts residents at risk for infection and deterioration of the stoma site (a surgically created opening on the outside of your body that connects to an organ on the inside).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 9 residents (Residents #1) reviewed for resident rights in that: The facility failed to ensure Residents #1's call light was answered in a timely manner. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for the resident's welfare and the resident's needs could not be met in the facility for 1 of 9 residents (Resident #2) reviewed for discharge requirements. The facility failed to ensure Resident #2 was readmitted to the facility, after being sent to the hospital for behaviors. This failure could place discharged residents and residents residing in the facility at risk of being discharged and not allowed to return to the facility causing a disruption in their care and/or services.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 3 of 8 resident (Residents #1, #2, and #3) reviewed for activities of daily living. The facility failed to ensure Residents #1, #2, and #3 were provided care and services for hygiene. This failure could place residents at risk for poor self-esteem, infections, socialization, ADL decline and diminished quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat each resident with respect and dignity and care in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality, for 9 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9) of 24 secure unit residents reviewed for dignity. The facility failed to ensure LVN A treated Residents #1, #2, #3, #4, #5, #6, #7, #8 and #9 who were sitting in the dining area in the memory care unit with dignity and respect when she referred to the residents' clothing protectors as bibs to CNA B. This failure could place residents at risk for psychosocial harm due to diminished self-esteem and quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 (MA C) of 3 staff reviewed for authorized drug destruction personnel. The facility failed to ensure a licensed professional was a witness to the drug destruction. MA C witnessed and handled controlled and non-controlled medications during the drug destruction process with the DON. This failure could place residents at risk of drug diversion.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store food in accordance with professional standards for food service safety for 1 of 1 kitchens reviewed for kitchen sanitation. The facility failed to ensure dietary staff stored disposable plates and cups away from chemicals and cleaning supplies. This failure could place residents at risk of cross-contamination, food contamination, and foodborne illness.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for 1 of 1 kitchen reviewed for food storage and labeling in that: 1. The facility failed to ensure food and beverages were safely stored, labeled, and dated. in refrigerator #1, refrigerator #2, and freezer #1, freezer #2 and in the dry storage area on 05/14/24. 2. The facility failed to ensure kitchen staff DC #2 and DC #3 were properly wearing hair nets and properly wearing and changing gloves on 05/14/2024 and 05/15/2024. These deficient practices could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 3 (Residents #5, #28, and #29 ) of 16 residents reviewed for resident rights. 1. The facility failed to treat Resident #28 with respect and dignity on 5/14/2024 during the Hoyer transfer to keep her body covered. 2. The facility failed to treat Resident # 5 with respect and dignity on 5/14/2024 during wound care, by not closing the door to the room or pulling the privacy curtain. 3. The facility failed to treat Resident's # 5 on 5/14/2024 and # 29 on 5/17/2024 by always keeping a privacy bag on the foley drainage bag. These failures 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 maintain a safe, functional, sanitary, and comfortable environment for 5 (Rooms 28, 32, 34, 36, and 64) of 20 resident rooms reviewed for environment. The facility failed to ensure the ceiling tiles in rooms [ROOM NUMBERS] were free from stains and drooping on 05/14/24, 05/15/24, and 05/16/24. The facility failed to ensure the blinds in rooms 28, 32, 36, and 64 were free from missing slats on 05/14/24, 05/15/24, and 05/16/24. These failures could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment, lack of privacy, and diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, 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 of 4 (Residents # 5, Resident # 10, Resident # 24 and Resident # 58) of 24 reviewed for comprehensive care plans. 1. The facility failed to ensure Resident # 5's care plan dated 5/3/2024 was resident by behaviors, mood and medication documented brief and generic. 2. The facility failed to ensure Resident # 10's care plan dated 4/11/2024 reflected his pain and interventions to ensure resident had the best possible quality of life. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident's drug regimen was free from unnecessary psychotropic medications for 1 of 5 residents (Resident #58) reviewed for unnecessary psychotropic medications. The facility failed to ensure Resident #58's order, dated 05/03/24, for the psychotropic medication lorazepam (an anti-anxiety medication) PRN was not ordered beyond 14 days without an end date. The facility failed to ensure Resident #58 was monitored for side effects and behaviors related to the use of Abilify (an antipsychotic medication) from 04/23/24 through 05/17/24, and lorazepam (an anti-anxiety medication) from 05/03/24 through 05/17/24. These failures could place residents at risk for receiving unnecessary medication, unwanted side effects, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents were free of a medication error rate of 5% or greater (10.34%) for 3 (Resident #1, Resident #50, and Resident #54) of 5 residents reviewed for medication administration. 1) The facility failed to ensure LVN A primed the insulin pen prior to administering insulin to Resident #1 on 05/14/24. 2) The facility failed to ensure MA E administered Senna 8.6mg as ordered instead she gave Senna-S 8.6mg/50mg to Resident #50 on 05/15/24. 3) The facility failed to ensure LVN B primed the insulin pen prior to administering insulin to Resident #54 on 05/15/24. These failures placed residents at risk of incorrect doses and not receiving the intended therapeutic benefit of the medications prescribed by the physician.

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 control and labeled in accordance with currently accepted professional principles for 1 (medication room [ROOM NUMBER]) of 2 medication storage rooms and 2 (medication cart #1 and medication cart #2) of 4 medication carts reviewed for medication storage. Medication cart # 1 was left unattended and unlocked on 05/15/2024. Medication Cart #2 was left unattended and unlocked on the secure unit on 05/14/2024. An expired, opened and accessed, medication was stored in the medication room [ROOM NUMBER] refrigerator on 05/15/2024. [...]

Inspectors wroteBased on observations and interviews, the facility failed to prepare food and drink that are palatable, attractive and at a safe and appetizing temperature for two of three meals sampled in that: The facility failed to provide food that was palatable (vegetables with no flavor or seasoning) at a safe and appetizing temperature (sample tray was luke warm.] . This failure could place residents at risk of not being satisfied with their food, decreased food intake, unintended weight loss, hunger, poor nutrition, impeded recovery from illness and injury and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food prepared in a form designed to meet individual needs for two of three meals sampled. The facility failed to ensure the puree texture was in a form (pudding like consistency that was smooth) to meet resident needs for two of three lunch meals on (5/14/2024 and 5/15/2024) sampled by two (Surveyor # 2 and Surveyor #3) of four survey team members . These failures could place residents at risk of decreased food intake, choking and aspiration. .

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 to help prevent the development and transmission of communicable disease and infections in 14 ( Residents # 5,#9,#10, #23,#26,#28,#29,#31,#33, #41, # 58, # 61, and # 66) of 23 residents that were reviewed for infection control and transmission-based precautions policies and practice in that: 1. The facility failed to ensure CNA I, MA J, MA K, CNA L and ST did not grab Resident's 9 (Resident #9, # 23. #26, # 29 #31, # 33, #41, #61, and #69) of 23, cup by the rim with bare hands, contaminating the tops of the rims, during the meal service on the secure unit on 5/12/2024 and 5/13/2024 at lunch time. 2. The facility failed staff failed to follow hand hygiene 3(resident # 5, 10, and 28) of 23 A. [...]

Inspectors wroteBased on, interview, and record review the facility failed to ensure pain management was provided to residents who require such services, consistent with professional standards of practice, pain management services for 1 of 6 residents reviewed for pain. (Resident #10) The facility failed to ensure Resident # 10 received his scheduled Oxycodone 5mg every 4 hours for 5/11/2024 at noon to 5/13/2024 at 12:00am for a total of 13 doses. The facility failed to obtain an alternative medication for Resident #10's pain, until 5/12/2024 with the initial dose being given at 7:32 pm leaving Resident #10 in pain for over 24 hours. This failure placed residents at risk of increased pain and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide routine dental services to 1 of 2 (Resident #1) residents reviewed for dental services. The facility failed to provide routine dental services for Resident #1, since admission on [DATE], who was being treated for an oral infection. This failure could place residents at risk for decline in oral health, oral infections, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure nurse staffing data including the facility name, the current date, the total number and the actual hours worked was posted and readily accessible to residents and visitors for 2 (05/14/24 and 05/15/24) of 3 days reviewed for nurse staffing information. The facility failed to post the required staffing information on 05/14/24 and 05/15/24. The facility failed to post the required staffing information in a prominent place readily accessible to residents and visitors on 05/14/24. These failures could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on observation, interview, and record review, the facility failed to care for residents in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of one resident (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's bed was moved, per request, as outlined in his care plan, to allow him for more space. This failure could place the residents at risk for depression and unmet needs.

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 one of one kitchen reviewed for general sanitation. 1. The facility failed to ensure that wastewater from the toilet in the kitchen bathroom did not leak into the kitchen. 2. The facility failed to ensure that a bucket of waste material in the facility kitchen was disposed of properly. 3. The facility failed to ensure that the area around the ice machine was free of wastewater. An IJ was identified on 09/21/23. The IJ template was provided to the facility on [DATE] at 05:25 PM. [...]

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 one of one kitchen reviewed for infection control. 1. The facility failed to ensure that wastewater from the toilet in the kitchen bathroom did not leak into the kitchen. 2. The facility failed to ensure that a bucket of waste material in the facility kitchen was disposed of properly. 3. The facility failed to ensure that the area around the ice machine was free of wastewater. An IJ was identified on 09/21/23. The IJ template was provided to the facility on [DATE] at 05:25 PM. [...]

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 one of one kitchen reviewed for food service safety. The Dietary Manger failed to ensure all items were stored properly, labeled, dated, and discarded prior to their expiration date. The Dietary Manger failed to ensure the handwashing sink was stocked with paper towels. CK J failed to properly wash her hands between tasks. These failures placed residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment for ten (Resident #3, Resident #11, Resident #13, Resident #15, Resident #20, Resident #23, Resident #44, Resident #49, Resident #55, and Resident #58) of 24 residents reviewed for a clean, comfortable, and organized environment. Window blind slats were missing from the blinds for residents #3, #11, #13, #15, #20, #23, #49, #55, and number 58. The Smoking area for residents #13, #44, and #55 was not cleaned and organized Ceiling tiles were missing from the outside hallway to the main central nurse's station. The failure could result in a diminished quality of life and prevent these residents from attaining their highest practicable well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to follow the menu for three (Resident #15, Resident #17, and Resident #41) of eight residents reviewed for portion size adequacy. CK J served Resident #15, Resident #17, and Resident #41 pureed food items using scoops smaller than required per the facility's menu. This failure placed residents at risk of poor intake, weight loss, and malnutrition.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all residents received food and drinks that accommodated their preferences for four (Resident #11, Resident #14, Resident #17, and Resident #41) of eight residents reviewed for food and drink preferences. 1. TNA H failed to provide coffee requested by Resident #11. 2. Dietary staff failed to provide Resident #14 with ice cream per his tray ticket and physician's order. 3. LVN B failed to offer Resident #41 an additional helping of food when he finished his plate and was still hungry. 4. Nursing staff failed to offer Resident #17 an additional helping of food when she finished her plate and appeared still hungry. These failures placed residents at risk of hunger and not receiving their food and drink preferences.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for two of two residents (Residents #17 and Resident #15) reviewed for resident rights. The facility failed to ensure Resident #15 and Resident #17 were fed by a staff member sitting at eye level rather than standing over them. This failure could place residents at risk for a diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 1 of 2 residents reviewed for medication administration (Resident #62) and for 1 of 1 resident (Resident #169) reviewed for incontinent care as indicated by: MA E failed to properly sanitize blood pressure cuff when moving from one resident to another resident when administering medications and obtaining blood pressure for Resident #62. CNA G failed to wash or sanitize her hands while going from a dirty to clean surface when performing incontinent care on Resident #169. This deficient practice placed all residents identified at risk for cross contamination and the spread of infection.