Avir at Cisco

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 1 of 5 employees (NA-A) reviewed for employability. The facility failed to ensure the record of the initial criminal history check, employee misconduct registry check, and nurse aide registry check was obtained for NA-A, hired on 01/01/2026, prior to working in the facility and having access to the residents. This failure could place residents at risk of receiving care by someone that was unemployable.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #21) of 18 residents reviewed for comprehensive person-centered care plans. The facility failed to develop a care plan based on the assessed needs with measurable objectives and timeframes in area of colostomy for Resident #21. This failure could place the residents at risk for decreased quality of life and not having their needs met.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 100 of 403 (June 8, 2023 to July14, 2024) days reviewed for RN coverage. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received food that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 lunch meal tested for nutritive value, flavor, appearance, and temperature. The facility failed to ensure that 38 of 38 residents who received meals from the kitchen received food that was palatable, attractive, and at a safe and appetizing temperature. This failure place residents at risk of poor food intake and/or dissatisfaction of meals served.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that have the ability to be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 14 (Resident # 29, #30, and #37) residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans that incorporated Resident #30 and #37's to include the use psychotropic medications. The facility failed to develop care plan that incorporated Resident #29's identified pressure ulcers. These failures could place the residents at risk for decreased quality of life and not having their needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections for halls 1 of 3 halls. The facility staff (CNA C) failed to place dirty linens in a sealed bag before being transported from resident room. The facility staff failed (CNA D) to place dirty briefs after peri-care in a sealed back before being transported from resident room. These failures could place residents at risk for the spread of infection and skin complications.

Inspectors wroteBased on observations, interviews, 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 and assistance devices to prevent accidents for 1 of 1 resident (Resident #28) reviewed for accidents and supervision. The facility failed to ensure CNA-E and CNA-F locked the Resident wheelchair during the Hoyer transfer of Resident #28. This failure could place residents at risk of injuries.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in permanently affixed compartments during medication storage inspection for 1 (cart #1) of 4 medication carts reviewed for storage. The facility failed to ensure medication cart #1 was locked and secured while unattended. This failure could result in a drug diversion.

Inspectors wroteBased on interviews, and record review the facility failed to maintain medical records on each resident, in accordance with accepted professional standards and practices, that were complete and accurate for 1 of 14 (Resident #29) residents reviewed for resident records. The facility failed to ensure Resident #29 had orders for weekly skin assessments. This failure could place residents at risk of having errors with their care and treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident had a right to be treated with respect and dignity for 1 of 3 (Resident #2) residents reviewed for urinary catheter care. The facility failed to place Resident #2's urinary catheter in a privacy bag. This failure could place residents at risk of low self-esteem resulting in a diminished quality of life.

Inspectors wroteBased on observation, interview, 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, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 3 residents (Resident #6) reviewed for respiratory care. The facility failed to ensure Resident #6's nebulizer tubing was kept in bag while not in use. These failures could place residents at risk for respiratory infections.

Inspectors wroteBased on interviews and record reviews, the facility failed to utilize the services of an RN for 8 consecutive hours 7 days a week for 47 days out of 154 days reviewed. The facility failed to have an RN for 8 consecutive hours 7 days a week for 47 days out of 154 days reviewed from January 1, 2023, through June 4, 2023. These failures could place all residents at risk for their clinical needs not being met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for 1 of 1 kitchen's reviewed for food service safety. The facility failed to label items in refrigerators and freezers. The facility failed to discard items in a timely manner that were stored in refrigerators and freezers. The facility failed to seal items that were stored in the refrigerators and freezers. These failures placed all residents at risk of complications of foodborne illnesses.

Inspectors wroteBased on interviews and record reviews the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand for 2 (Resident #16 and Resident #27) of 4 residents reviewed for discharge. The facility failed to notify Resident #16 or her representative of her transfer in writing. The facility failed to notify Resident #27 or his representative of his transfer in writing. These failures place residents and/or their resident representatives at risk of understanding the reasons and/or location of transfers.

Inspectors wroteBased on observation, 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 time frames to meet a resident's medical, nursing, and mental and psychosocial needs, for two (Resident #21, Resident #33) of eight residents reviewed for care plans, in that: The facility failed to address the care and monitoring of Resident #21's left lower leg prosthetic and the risk for skin breakdown on the comprehensive care plan. The facility failed to address the care and monitoring of Resident #33's indwelling urinary catheter and colostomy These failures could place residents at risk for not having their needs met.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who enters the facility with an indwelling catheter or subsequently receives one is assessed for removal of the catheter as soon as possible unless the resident's clinical condition demonstrates that catheterization is necessary for 1 (Resident #33) of 3 residents reviewed for indwelling catheters. The facility failed to have a diagnosis, physician orders and care plan interventions for Resident # 33's indwelling urinary catheter. These findings place resident at risk of complications related to urinary catheterization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who enters the facility with a colostomy receive such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident ' s goals and preferences for 1 (Resident #33) of 2 residents reviewed for colostomies. The facility failed to have a diagnosis, physician orders, and care plan for Resident # 33's colostomy. These findings place resident at risk of complications related to a colostomy.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide a written bed hold policy for 1 of 1 facility reviewed for transfers and discharges. The facility failed to have a written bed hold policy. This failure placed residents at risk of returning to their room in the facility upon return from emergent transfers.