Avir at Cowhorn Creek

Inspectors wroteBased on and record review, the facility failed to develop and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 1 of 7 residents (Resident #1) reviewed for care plans.1. The facility failed to implement Resident #1's care plan by not performing a mechanical lift.2. The facility failed to implement Resident #1's care plan when CNA A attempted to transfer Resident #1 by himself on [DATE] by lifting her under her arms. These failures could place residents in the facility at an increased risk of injury, a decline in physical or functional well-being, and not receiving necessary care or services to meet their needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident's environment remained as free of accident hazards as was possible and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for accidents and supervision. 1. The facility failed to ensure CNA A did not attempt a one-person resident transfer from the shower chair to Resident #1's wheelchair and then from her wheelchair to her bed on [DATE] by lifting her under her arms.2. The facility failed to ensure CNA A and CNA B performed a safe transfer from Resident #1's wheelchair to her bed on [DATE] by lifting her under her arms without the use of a gait belt or other assistive devices.3. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 4 residents (Resident #1) reviewed for accidents and supervision, in that: Resident #1 was transferred without a gait belt and staff failed to utilize safe body mechanics during the transfer on 6/22/26. This failure placed the residents at risk for loss of balance, fall, and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate administering of all drugs and biologicals, to meet the needs of 1 of 1 residents reviewed for pharmacy services. (Resident #1)The facility failed to accurately administer medications for Resident #1 when LVN A administered 15 medications late. This failure could place residents at risk for inaccurate drug administration and worsening of condition.

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to ensure RN coverage for 5 days during FY Quarter 4 2025 (July 1 to September 30). This failure could place residents at risk of harm due to being left without supervisory coverage for coordination of events such as emergency care and disasters.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety.1. The facility failed to ensure equipment surfaces were kept clean.2. The facility failed to ensure that all food items in Refrigerator #1, Refrigerator #2, and Freezer #1 were dated and labeled.3. The facility failed to ensure that the outside of the fryer and the side of the range facing the fryer were kept free of grease build up. These failures could place residents at risk of foodborne illness and food contamination. Record review of a blank Daily Cleaning Schedule indicated the cooks were to clean the stove and cook area after each meal. Record review of a blank Weekly Cleaning Schedule indicated the deep fryer was to be cleaned by the cook on Wednesday. [...]

Inspectors wroteBased on interview and record review the facility failed to complete the admission assessment for 5 of 18 (Resident #28, Resident #44, Resident #53, Resident #55, and Resident #72) residents reviewed for MDS completion. The facility failed to complete the admission MDS assessment for Resident #28, Resident #44, Resident #53, Resident #55, and Resident #72 within 14 calendar days. These failures could place residents at risk of not having records completed and submitted in a timely manner as required

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS admission assessment was transmitted to the CMS System within 7 days after completion for 1 of 18 residents (Resident #7) reviewed for admission MDS assessments. The facility failed to ensure Resident#7's admission MDS assessments were transmitted within 14 days of completion of admission assessment. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on interviews and records reviews, 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 are identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #5, Resident #14, Resident #41 and Resident #59) of 18 residents reviewed for care plans. 1. The facility failed to ensure Resident #5 had a complete comprehensive care plan.2. The facility failed to ensure Resident #14 had a care plan for hospice services.3. The facility failed to ensure Resident #41 had care plans for falls and psychotropic medication usage as coded on the MDS.4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to remove expired medications from active storage for 1 of 2 medication rooms (Medication room [ROOM NUMBER]). 1. The facility failed to ensure expired insulin and expired OTCs were removed from active storage in medication room [ROOM NUMBER]. 2. This failure could place residents at risk of expired medication being administered.3. Resident #15's Basaglar (long-acting insulin) 20 Units each morning was held for 19 of 41 days reviewed with no MD order to hold or notification of MD from 01/01/2026 through 02/10/2026. These failures could affect residents that are insulin dependent by placing them at risk for elevated blood glucose and poor glucose control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and attractive for 3 of 8 residents (Resident's #5, #32, and #39) reviewed for palatable food. The facility failed to provide food that was palatable and attractive to Resident #5, #32, and #39 who complained the food was served cool and bland. These failures could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

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 1 of 4 halls (hall 300) and 1 of 6 (Resident #59) residents reviewed for infection control practices. 1. The facility failed to ensure staff (CNA B) maintained infection control prevention while carrying soiled linen through the facility on 02/09/2026. 2. The facility failed to ensure staff (LVN A) wore PPE when providing direct care to a resident on EBP. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents received services in the facility with reasonable accommodation of resident needs 2 of 18 residents reviewed for accommodation of needs (Resident #14 and #26). The facility failed to ensure the call light was in reach on multiple occasions on 02/09/2026-02/10/2026 to call for assistance for Resident #14 and Resident #26. This failure could place residents at risk of decreased physical and psychosocial wellbeing and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had a right to organize and participate in resident groups in the facility for 1 of 8 residents reviewed for resident council. (Resident #39) The facility did not ensure Resident #39 was able to attend resident council meetings, as they were scheduled on her dialysis days. This failure could place residents at risk for decreased quality of life and resident rights not being honored.

Inspectors wroteBased on interview and record review the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of charges for those services, which included charges for services not covered under Medicare/Medicaid or by the facility's per diem rate for 1 of 3 residents (Resident #74) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #74 was given a SNF ABN (is document that informs a Medicare beneficiary that Medicare will no longer pay for skilled services) when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident who experienced a significant change in status is comprehensively assessed using the CMS-specified Resident Assessment Instrument (RAI) process for 1 of 8 residents reviewed for significant changes in status (Resident #14). The facility failed to comprehensively assess Resident #14 when she elected hospice services using the CMS-specified RAI process. This failure could place residents at risk of not receiving needed care and services.

Inspectors wroteBased on interview and record review the facility failed to ensure an accurate MDS assessment was completed for 1 of 18 residents reviewed for MDS accuracy. (Resident #1) The facility failed to accurately code Resident #1's significant weight loss of 12.8% in 180 days. This failure could place residents at risk of not receiving needed care and services.

Inspectors wroteBased on interview, and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program to include all residents with newly evident or possible serious mental disorder for 1 of 5 residents (Resident #9) reviewed for the PASRR program. The facility failed to ensure Resident #9 was referred for a PASRR (Level II) evaluation when she received a new mental illness diagnosis. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Record review of the face sheet, dated 02/10/26, indicated Resident #9 was [AGE] years old. The face sheet indicated an admission date of 01/19/22 with an original admission date of 09/01/20. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure necessary services to maintain grooming and personal hygiene were provided for 1 of 4 residents reviewed for ADLs. (Resident #39) The facility did not ensure Resident #39 was assisted with brushing her hair. These failures could place residents at risk of not receiving care or services, decreased quality of life, embarrassment, and decreased self-esteem.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that 1 of 17 residents reviewed for vision services, received proper treatment and assistive devices to maintain vision abilities. (Resident #9)The facility failed to follow up on an eye doctor's recommendation to order glasses for Resident #9. This failure could affect residents by causing them to have decreased vision awareness when ambulating, difficulty seeing and participating in activities, and decreased self-esteem. Record review of the face sheet, dated 02/10/26, indicated Resident #9 was [AGE] years old. The face sheet indicated an admission date of 01/19/22 with an original admission date of 09/01/20. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure adequate supervision and assistance devices to prevent accidents for 1 out of 2 residents (Resident #47) reviewed for transfers. The facility failed to ensure CNA D and CNA F performed a proper gait belt transfer on Resident #47 on 02/09/2026. This failure could place residents at risk of injuries, such as arm dislocation and fractures, during transfers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 8.0%, based on 3 errors out of 25 opportunities, which involved 2 of 4 residents (Resident #15, Resident #59) reviewed for medication administration. 1. The facility failed to administer Resident # 15's Basaglar Insulin (a long-acting insulin injected once daily to improve blood sugar control in adults with type 2 diabetes and adults/children (6+ years) with type 1 diabetes) 20 Units every morning. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that accommodates resident allergies, intolerances, and preferences 1 of 8 residents (Resident #32) reviewed for resident food preferences. The facility failed to ensure Resident #32's dislike of pork was honored during the breakfast meal on 02/10/2026 and the lunch meal on 02/11/2026. This failure placed residents at risk for not having their nutritional needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 2 of 5 resident personal refrigerators reviewed for food safety (Resident #12 and Resident #63). The facility failed to ensure the refrigerator for Resident #12 and Resident # 63 were clean and did not contain expired food. This failure could place residents at risk for food borne illnesses.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse for 1 of 13 residents (Resident #1) reviewed for resident abuse. The facility failed to ensure Resident #1 was free from abuse, as evidenced by video footage of multiple incidents where direct care staff had inappropriate interactions towards Resident #1, such as staff making inappropriate and disrespectful comments towards the Resident and failing to maintain the Resident's dignity by leaving the Resident exposed and in view of individuals who could have walked by, not allowing the Resident time to communicate her needs, not feeding resident timely, and not identifying when Resident #1's head was not in the appropriate position for using her communication device, ease of breathing and eating. An immediate jeopardy (IJ) was identified on 8/14/25 at 3:25 PM. [...]

Inspectors wroteBased on observation, interview and record review; it was determined the facility failed to ensure each resident received the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1 of 13 residents reviewed for Quality of Life. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to file a grievance report and investigate the grievances reported by a resident for 1 of 13 residents (Resident #1) reviewed for grievances. The facility failed to investigate Grievances/concerns when Resident #1 reported to the DON by emails on 7/05/25, 7/09/25, 7/12/25, 7/21/25, 7/22/25, 8/02/25, 8/03/25, 8/04/25, 8/07/25 and 8/08/25 related to not answering her call light timely, staff mistreatment, the lack of care she was receiving, and not being fed completely/timely. The facility failed to document Resident #1's grievances/concerns on the Grievance/Concerns log forms for the reported dates of 7/05/25, 7/09/25, 7/12/25, 7/21/25, 7/22/25, 8/02/25, 8/03/25, 8/04/25, 8/07/25 and 8/08/25. These failures could place residents at risk for abuse, neglect, and not having their needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote resident self-determination through support of resident choice for 1 of 7 residents reviewed for resident rights. (Resident #2)The facility failed to assist Resident #2 out of bed as often has she preferred. This failure could place dependent residents at risk for feelings of depression, lack self-determination and decreased quality of life. Record review of a face sheet dated 08/12/25 revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 4 residents reviewed for ADLs. (Resident #2)The facility failed to provide Resident #2 with her scheduled showers. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Record review of a face sheet dated 08/12/25 revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure food was provided that accommodated the preferences of 1 of 7 residents reviewed for preferences. (Resident #2) The facility did not honor Resident #2's food preferences after she made a request to the Dietary Manager on 08/04/25 that her meat be chopped. This failure could place residents at risk for dissatisfaction, poor intake, and/or weight loss. Record review of a face sheet dated 08/12/25 revealed Resident #2 was [AGE] years old and admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually, to include the resident population, diseases, conditions, physical and behavioral health needs, cognitive status, acuity of the resident population, and other pertinent information for 1 of 1 facility. The facility failed to include Resident #1's diagnosis of Amyotrophic Lateral Sclerosis (ALS) (a nervous system disease that causes muscle weakness and paralysis (unable to move) and impacts physical function, ability to talk and breathe). These failures could affect residents by not having the necessary resources to ensure appropriate care was provided.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to treat each resident with respect and dignity and provide care in a manner that promoted maintenance or enhancement of his or her quality of life for 1 of 7 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated with respect, dignity, and provided with care that enhanced her quality of life when: * CNA B told Resident #1 she wished she would tell her not to come back in her room and she guessed she would not be back in on that day. * CNA C hid a can of air freshener and sprayed the top of Resident #1's top of bed, pillow, and her head and then told Resident #1 It stank up in here, it stank up in here. * CNA D told Resident #1 she had 10 minutes; he would be in her room [ROOM NUMBER] minutes or less; it was frustrating for the both of them; [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to file a grievance report and investigate the grievance reported by a resident's representative for 1 of 7 residents (Resident #1) reviewed for grievances. The facility failed to investigate Grievances/concerns when Resident #1 reported to ADON A by emails on 1/05/25, 2/03/25, and 2/06/25 related to the lack of care she was receiving and not answering her call light. The facility failed to document Resident #1's grievances/concerns on the Grievance/Concerns log forms for the reported dates of 1/05/25, 2/03/25, and 2/06/25. These deficient practices could place residents at risk for abuse, neglect, and not having their needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from abuse for 1 of 7 residents (Resident #1) reviewed for resident abuse. 1. The facility failed to ensure Resident # 1 was free from abuse when CNA C hid a can of air freshener and sprayed the top of Resident #1's top of bed, pillow, and her head on 12/26/24. 2. The facility failed to ensure Resident #1 was free from abuse when CNA E abruptly grabbed Resident #1 by both shoulders and roughly positioned her more upright in bed and spoke to her in a loud rude tone on 12/27/24. These failures could place residents at risk of physical harm, mental anguish, and/or emotional distress.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards in 1 of 1 kitchen reviewed for food service safety. 1. The facility failed to ensure the sugar was stored in a bin with a closed lid. 2. The facility failed to ensure all food items were labeled and dated in Freezer #1. 3. The facility ensure the deep fryer was clean free of grease splashes and food particles. 4. The facility failed to ensure the doors of Freezer #1, Refrigerator #1 and the lid of the milk cooler was clean and free of food smears. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the residents and/or representatives had the right to participate in the development and implementation of his or her person-centered plan of care, and to ensure that the planning process facilitated the inclusion of the residents and/or representatives for (AR #1, AR #2, AR #44, AR #6, and AR #8). The facility failed to ensure , AR #1, AR #2, AR #44, AR #6, and AR #8, were involved in the review of the comprehensive assessment and were able to discuss their individualized care needs for services to include their need for medical and nursing care, medications, therapy, psychological and dietary needs. The failure could affect residents by placing them at risk for not receiving adequate or individualized care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 8 of 17 residents (Resident #4, Resident #19, Resident #27, Resident #29, Resident #36, Resident #38, Resident #54, and Resident #64) and 4 anonymous residents reviewed for palatable food. 1. The facility failed to ensure residents received food that tasted good. 2. The facility failed to ensure residents did not receive cold food. 3. The facility failed to provide condiments such as salad dressing, sugar, and coffee creamer to residents. These failures could place residents at risk of weight loss, altered nutritional status and diminished quality of life.

Inspectors wroteBased on interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack was served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 6 of 8 residents (confidential residents in group) reviewed for frequency of meals. The facility failed to ensure residents were offered snacks at bedtimes as required due to mealtimes being more than 14 hours apart. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for, unplanned weight loss, and side effects from medication given without food, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 20 residents (Resident #31) reviewed for reasonable accommodations. The facility failed to ensure Resident #31's, call button was within reach while in bed. This failures could place residents at risk for a delay in assistance and decreased quality of life, self-worth, and dignity.

Inspectors wroteBased on interview and record review the facility failed to send a copy of the notice of facility-initiated discharge to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 3 residents (Resident #59) reviewed for discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #59 was discharged to another facility on 11/15/2024. This failure could place residents at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 2 of 6 residents reviewed for new admissions (Residents #28 and #177). The facility did not ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was provided to the resident and/or their representative for Resident #28. The facility did not ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for Resident #177. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that 1 of 17 residents reviewed for vision services, received proper treatment and assistive devices to maintain vision abilities. (Resident #47) The facility failed to transport Resident #47 to an appointment with an ophthalmologist on 10/02/24 and 12/04/24. This failure could affect residents by causing them to have decreased vision awareness when ambulating, difficulty seeing and participating in activities, and decreased self-esteem.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received appropriate treatment and services to prevent further decrease of ROM for 1 of 4 residents reviewed for limited range of motion. (Resident #68) The facility did not ensure Resident #68 had a contracture prevention services in place for the treatment of his left sided hemiplegia with decreased range of motion. This failure could place residents at risk for decrease in mobility, range of motion, and contribute to worsening of contractures.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 1 of 20 residents (Resident #72) reviewed for nutrition. The facility failed to follow the facility's weight policy of weighing Resident #72 after a 11.3-pound weight loss from admission on [DATE] to 11/1/2024 indicating a 5.51% weight loss. There was no weight obtained within 24 hours after signification weight loss >5 % on 11/1/2024. This failure could place residents at risk for malnourishment, weight loss, skin breakdown, and decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a gradual dose reduction was attempted for 1 of 3 residents (Resident #39) reviewed for unnecessary medications/ gradual dose reduction. The facility failed to ensure a gradual dose reduction (GDR) was attempted or document contraindication for a gradual dose reduction for Resident #39's ordered Abilify (antipsychotic medication used to treat certain mental/mood disorders) 5 milligrams orally daily ordered 06/29/23. This failure could place residents at risk for possible psychotropic medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #59) reviewed for discharge MDS assessments. The facility did not ensure Resident #59's discharge MDS assessment was completed and transmitted within 14 days of completion. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.

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 and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1of 5 residents (Residents #2) reviewed for dignity. The facility failed to ensure CNA B did not feed Resident #2 while standing on 10/23/2024. The failure could place residents at risk for a diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 of 5 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #3 did not verbally abuse Resident #1 on 10/14/2024. This failure could place residents at risk of abuse, physical harm, mental anguish and emotional distress.

Inspectors wroteBased on observation, 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, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. [...]

Inspectors wroteBased on observation, 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, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 5 residents (Resident #1) reviewed for abuse and neglect. The facility failed to investigate Resident #1's family member's allegation that Resident #3 was verbally abused by Resident #1 on 09/29/2024. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 (Resident #4) residents reviewed for accidents. The facility failed to ensure CNA E used two-person assistance to transfer Resident #4 out from the recliner to the bed which resulted in a fall without injury on 10/10/2024. This failure could place residents at risk of injuries, falls and hospitalizations.

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 1 of 5 residents (Resident #2) reviewed for infection control practices and transmission-based precautions. The facility failed to ensure LVN A performed hand hygiene after he removed his gloves when he provided incontinent care to Resident #2 on 10/24/2024. This failure could place residents at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to ensure a resident had the right to a dignified existence and was treated with respect for 1 of 4 residents reviewed for rights. ( Resident #1) The facility failed to ensure CNA A provided Resident #1 with care when she activated her said staff often come into her room and turn the call light, CNA A entered the room turned the call light off and left the room. without providing any care or consideration due to her speech impairment and them not wanting to take the time and listen. CNA A was seen in a video turning off Resident #1's call light without providing her assistance. This failure placed residents at risk of deficient practice could cause the resident not receiving needed care and services, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident receives and the facility provides food prepared in a form that meet the resident needs for 1 of 4 residents reviewed for puree food. (Resident #1) The facility failed to ensure Resident #1's pureed breakfast meal was the correct consistency and not bland. This deficient practice could place residents at risk for weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 21 (Residents #38, #29, #59 and #49) residents reviewed for care plans. 1. The facility failed to ensure Resident #38's comprehensive care plan addressed that she required Lasix (a diuretic medication used to reduce extra fluid in the body (edema) caused by conditions such as heart failure, liver disease, and kidney disease). 2. The facility failed to ensure Resident #29's left-hand contracture (a permanent tightening of the muscles, tendons, skin, and surrounding tissues that causes the joints to shorten and stiffen) was care planned. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were seen by a physician at least once every 30 days for the first 90 days after admission for 4 of 21 residents (Resident #'s 38, 59, 31 and 4) reviewed for physician services. The facility failed to ensure Resident #38, Resident #59, Resident #31, and Resident #4 were seen by a physician within the first 30 days of their admission to the facility. These failures could place the residents at risk for medical conditions not being identified, care needs not being met, and a decline in health status.

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 and to help prevent the development and transmission of communicable diseases and infections for 3 of 21 residents (Resident #13, Resident #31, and Resident #39) reviewed for infection control practices and transmission-based precautions. The facility failed to follow their policy for testing residents and staff following a COVID-19 outbreak in the facility after Resident #13 and Resident #31 tested positive for COVID-19. The facility failed to ensure LVN G performed hand hygiene and glove change while providing wound care for Resident #39. These failures could place residents and staff at risk for cross-contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 2 of 21 residents (Resident #59 and Resident #24) reviewed for MDS assessment accuracy. 1. The facility failed to accurately code Resident #59's diagnosis of schizophrenia (mental illness that causes delusions, or fixed beliefs that seem real, and hallucinations, or hearing voices that are not real) on his quarterly MDS assessment. 2. The facility inaccurately coded Resident #24 taking an anticoagulant medication on her quarterly MDS assessment dated [DATE]. These failures could place residents at risk for not receiving care and services to meet their needs .

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 2 residents (Resident #59) reviewed for resident assessments. The facility failed to refer Resident #59 for PASRR review following new mental illness diagnoses for paranoid schizophrenia (mental illness that causes delusions, or fixed beliefs that seem real, and hallucinations, or hearing voices that are not real) and PTSD (post-traumatic stress disorder)(mental health condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress anxiety, flashback and avoidance of similar situations). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carryout activities of daily living received services to maintain grooming and personal hygiene for 2 of 6 residents (Resident #'s 26 and 117) reviewed for quality of life. The facility failed to provide Residents #26 and #117 with a routine shower and shave. These failures could place residents at risk for and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 6 residents (Resident #4) reviewed for quality of care. The facility failed to ensure Resident #4's low air loss mattress (designed to distribute the patient's body weight over a broad surface area and help prevent skin breakdown) was on the correct settings. These failures could place residents at risk for deterioration of wound.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 6 residents reviewed for quality of care. (Resident #29) The facility did not provide interventions for Resident #29's left hand contracture. This failure could place residents who had contractures at risk of not attaining/or maintaining their highest level of physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 2 of 5 residents (Residents #4 and #38) reviewed for hydration. 1. The facility failed to ensure Resident #4 received adequate nutrition for wound healing. 2. The facility failed to ensure Resident #38 received adequate hydration. These failures could place residents at risk for dehydration, electrolyte imbalance, slow healing of pressure injuries, and continued poor skin health.

Inspectors wroteBased on interview and record review the facility failed to have adequate monitoring in place for side effects associated with the use of psychotropic medications and documented in the clinical record for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #13). The facility failed to adequately monitor Resident #13's behaviors regarding his psychotropic medications, including valium (an antianxiety medication), buspirone (antianxiety medication), and paroxetine (an antidepressant medication). These failures could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.

Inspectors wroteBased on observation and interview the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles for 1 of 2 medication carts (300/400 Hall nurse cart) reviewed for cleanliness. The facility failed to ensure the Medication Cart #1 (300/400 nurse medication cart) was free from a dried, tacky substance in the 3rd large drawer, and #4 and #5 small drawers. This failure could result in residents not receiving an accurate dose of medication as not being maintained at their best therapeutic level.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 2 residents (Resident #42 and Resident #20) reviewed for hospice services. The facility failed to maintain Resident #42 and Resident #20's hospice binder. This deficient practice could place residents who receive hospice services at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care, and communication of resident needs.

Inspectors wroteBased on interview and record review, the facility failed to develop, implement, and maintain annually an effective training program for existing staff, consistent with their expected roles for 5 of 21 employees (Speech Therapist, Occupational Therapist, Physical Therapist, CNA K, and CNA M) reviewed for required trainings. The facility failed to ensure the Speech Therapist, the Occupational Therapist, and the Physical Therapist received restraint training annually. The facility failed to ensure CNA K, CNA M, the Speech Therapist, and the Physical Therapist received HIV training annually. These failures could place residents at risk for the inappropriate use of restraints and exposure to HIV.

Inspectors wroteBased on observation and interview the facility failed to post, in a form and manner accessible to the residents and resident representatives, the required information for the public and the facility for 3 out of 3 postings reviewed for resident rights, in that: The facility failed to post: *HHSC phone number *Contact information for the Ombudsman. *A statement that the resident may file a complaint with the State Survey Agency concerning any suspected violation of state or federal regulation, including but not limited to reside abuse, neglect, exploitation, misappropriation of property in the facility, and non-compliance with the advances directives requirements (42 CFR part 489 subpart I) requests for information regarding returning to the community. [...]