Avir at El Paso

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1 of 6 (Resident #1) residents reviewed for base line care plans. The facility failed to develop Resident #1's baseline care plan within 48 hours of re-admission on [DATE]. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increasing resident safety and safeguarding against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 1 of 6 residents (Residents #2) reviewed for records.-The facility failed to ensure RN C documented attempts to contact the family of Resident #2 after their fall on 05/26/26.-RN C inaccurately documented she notified the family of Resident #2 after their fall on 05/26/26 at 7AM.This deficient practice could place residents at risk of not having accurate documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident resided and received services in the facility with reasonable accommodation of resident needs and preferences for 4 of 7 residents (Resident #56, #65, #96, and #109) reviewed for accommodation of needs. The facility failed to ensure resident call light was within reach for Resident #56, #65, #96, and #109 on 05/04/2026. This failure could place residents at risk of having their needs unmet when they were unable to contact staff.1. Record review of Resident #56's face-sheet, dated 05/06/2026, revealed a [AGE] year-old female admitted [DATE] and readmitted [DATE]. Record review of Resident #56's Quarterly MDS assessment, dated 02/20/2026, revealed a BIMS score of 0, meaning severe cognitive impairment. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the necessary services for residents who were unable to carry out activities of daily living to maintain good grooming and personal hygiene for 6 of 24 residents (Resident #13, Resident #15, Resident #54, Resident #65, Resident #128, Resident #129) reviewed for ADL care. The facility failed to ensure Resident #13's, Resident #15's, Resident #65's, nails were trimmed, cleaned, and filed on 05/04/2026. The facility failed to ensure Resident #54's, Resident #128's, and Resident #129's nails were trimmed and filed on 05/04/2026. The facility failed to ensure Resident #111's toenails were trimmed and filed on 05/04/2026. This failure could place residents at risk of loss of dignity, risk for infections, and a decreased quality of life.1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure biologicals were stored in locked compartments and accessed by authorized personnel for 3 (Resident #3, Resident #74, and Resident #89) of 24 residents reviewed for medication storage. The facility failed to dispose of a dixie cup on 05/04/2026 by leaving a dixie cup with Zinc Oxide pomade (skin ointment) at Resident #3's, Resident #74's, and Resident #89's bedside, exposed and within reach of other residents. The facility failed to ensure a medication cart was locked when unattended. This failure could place residents at risk of access to medications not approved for administration by their physician.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to dispose of garbage and refuse properly for 2 of 2 dumpsters (Dumpster #1 and #2) reviewed for garbage disposal . -The facility failed to ensure the dumpster #1 and #2 was closed on 05/04/2026.-The facility failed to properly dispose/save 2 bed frames (1 nonrepairable), air conditioning unit, and lamp post light housing that was left outside the facility laundry room on 05/04/2026 thru 05/06/2026.- The facility failed to ensure dumpster #1 and was closed on 05/05/2026. This failure could place residents at risk of infestation of rodents and insects.

Inspectors wroteBased on observation, interview, 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 2 (Resident # 1 and Resident #39) of 8 resident's reviewed for infection control. The facility failed to ensure Resident #39's nasal canula was properly stored while oxygen was not in use. The facility failed on 05/04/2026 to properly monitor and store Resident #1's dentures and did not placed them in a denture cup, and they were left exposed in a see through plastic clear cup without a lid on it. These failure could place residents at risk of cross contamination resulting in acquired infection or illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident's room was equipped to assure full privacy for each resident by providing ceiling suspended curtain that extended around the bed for 1 of 5 (Resident #75) residents reviewed for privacy. -The facility failed on 05/04/2026 to 05/06/2026 to provide a privacy curtain to Resident #75 in a shared room. This failure placed the resident at risk for not having privacy to his side of the room, experiencing embarrassment, and a decreased sense of self-esteem.

Inspectors wroteBased on record review and interview the facility failed to maintain an effective training program for all new and existing staff providing services for 2 of 7 employees (CNA A and Dietary Aide E) reviewed for training completions. -The facility failed to ensure CNA A received annual training for 6 training subjects reviewed on 05/06/2026.-The facility failed to ensure Dietary Aide E received annual training for 4 training subjects reviewed on 05/06/2026. This failure places residents at risk to receive services or care from a staff member who was not informed on procedures.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #1) of 4 residents reviewed for fall assessment after an unwitnessed fall. The facility failed to ensure LVN P appropriately assessed Resident #1 following an unwitnessed fall on 03/14/2026. This failure could affect others by placing them at risk for complications related to untreated injuries. Record review of Resident #1's face sheet dated 04/21/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE] and then readmitted on [DATE]. [...]

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 3 (Resident #2, Resident #3 and Resident #4) of 4 residents reviewed for pharmacy services and 3 of 4 medication carts (Halls 100, 200, and 300) reviewed for medications.- The facility failed to ensure timely acquisition of Resident #2's Lyricand was not administered per physician's orders.- The facility failed to ensure timely acquisition of Resident #3's Pregabalin and was not administered per physician's orders.- The facility failed to ensure timely acquisition of Resident #4's Tramadol and was not administered per physician's orders.-The facility failed to ensure licensed staff signed off on the Controlled [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Residents #1) of 8 resident reviewed for accidents and supervision. The facility failed to ensure adequate supervision to prevent accidents for Resident #1 when, on 8/3/25, Receptionist A allowed him to leave the building without confirming with staff whether he could be outside independently or verifying if he was a visitor. Resident #1 made it across the border to another state and then to the port of entry to another country. Resident #1 required hospital treatment for dehydration. The noncompliance was identified as PNC. The IJ began on 8/3/25 and ended 8/4/25. The facility had corrected the noncompliance before the survey began. These failures placed residents at risk of injuries, hospitalization, and death.

Inspectors wroteBased on interview and record review, the facility failed to ensure that incidents and investigations were complete and accurately documented for 2 of 6 (Resident #1 and #2) residents reviewed for accuracy and completeness of records. 1. The facility failed to have complete and accurate documentation and investigation for an allegation of misappropriation and exploitation for Resident # 1. 2. The facility failed to complete an incident report or accurately document progress notes, when Resident # 2 exited the facility. These deficient practices could put residents at risk of not receiving needed services such as monitoring or supervision, and incident investigations.

Inspectors wroteThe facility failed to maintain a system to prevent Resident #1's personal money from being taken by a staff member.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 (Resident #2) of 6 residents reviewed for accident prevention. The facility failed to provide supervision when Resident #2 exited the facility on 6/23/25 and propelled herself in her wheelchair down towards the sidewalk exiting the parking lot of the facility. This failure could place residents at risk of a fall, weather exposure, or being run over by a moving vehicle, which could result in injuries.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to ensure LVN A and LVN B communicate to the physician the need to administer medications while pending G-Tube placement result from KUB. This failure could place residents at risk of unmet medical needs and a decreased in quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure labratory services were provided to meet the needs of the resident in accordance with professional standards of practice, and for 1 of 6 residents (Resident #1) reviewed for labratory service. The facility failed to ensure LVN A followed up with diagnostic lab for Resident #1's stat KUB order. This failure could place residents at risk of delayed treatment, unmet medical needs, and a decreased in quality of life.

Inspectors wroteBased on, interviews, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident medical, nursing and mental and psychosocial needs for 2 (Residents #1 and 2) of 4 residents reviewed for care plans. -The facility failed to ensure Resident #1 and 2's diagnoses of dysphagia (difficulty swallowing) was addressed on their care plan. This failure could place resident at risk for not having their individual needs met in a timely manner injury, and a decline in physical well-being.

Inspectors wroteBased on observation, interview, 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, recognizing each resident's individuality for 3 (Residents #5, #16 and #26 ) of 9 residents reviewed for dignity. Resident #16 did not have a privacy bag on his catheter bag. Resident# 5 and Resident# 26 had their names written on their clothes with black marker across their chest. This failure could place residents at risk of diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide reasonable accommodation of resident needs and preferences involving the call light for of 5 residents of 18 (Resident #76 #91, #278, #284, #286) in that: - Resident #76 had no access to his call light which was hanging behind his bed and in between the foot of his bed. - Resident #91 had no access to his call light which was lying on the floor at the foot of his bed. - Resident #278 did not have access to his call light which was lying on the floor next to his bed. - Resident #284 had no access to his call light which was lying on the floor. -Resident #286 did not have access to his call light which was hanging on the resident's bed frame. This deficient practice could affect the residents in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain good foot health for 3 (Resident #28, Resident #57, and Resident #284) of 16 residents reviewed for foot care. -The facility's CNA's and licensed nurses failed to provide foot care for Resident #28, Resident #57, and Resident #284. This failure could affect residents by placing them at risk for poor foot health, decreased personal hygiene, and a decline in their quality of life.

Inspectors wroteBased on the observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food sanitation and storage, in that: -The facility failed to ensure gallon of liquid in the refrigerator was properly closed. -The facility failed to ensure tub of chocolate icing was free from dried drippings around lid. These failures could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on observation, interview, 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. - The facility failed to ensure Residents # 13, 16 and 82's indwelling catheter tubing was not on the floor. - The facility failed to keep linen cart covers in the laundry room free of tears. These failures could affect the residents at risk for spread of infection through cross-contamination of pathogens and illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department and 1 tankless water heater reviewed for patient care equipment in safe operating condition. -The facility failed to maintain dryer in operation condition. -The facility failed to ensure the residents for hallway 200 of the facility had hot water in their showers and bathrooms. These failures could place residents at risk for harm by the facility's inability to provide clean sanitary linens and could place residents at risk for poor hygiene and health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable in that: -The facility failed to keep liquid medication bottle free from dried drippings in medication cart for 100 hall. This finding can lead to spills which obscure the label or cause the medication to be contaminated and affect the 26 residents that reside in 100 hall.

Inspectors wroteBased on the observations, interviews, and record reviews the facility failed to dispose of garbage and refuse properly for 1 of 1 dumpster reviewed for food safety requirements. -Dumpster had trash on the ground outside and around the dumpster. -Dumpster was left open and with food substance running down the side of it. This failure could result in providing harborage and breeding areas for insects, rodents and other pests which could infest the facility placing the residents at risk of illnesses, and living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure that services provided or arranged by the facility met professional standards of quality for 1 of 8 (Resident #1) residents reviewed for care, in that: The facility failed to provide care that included but not limited to assessing, evaluating, and responding to residents needs for Resident #1. On 08/10/24, LVN D did not conduct a thorough assessment of Resident #1 when informed by CNA C that Resident #1's family informed her the resident had stopped talking while eating and spit out a piece of meat. LVN D did not have her stethoscope to check lung sounds. LVN D, when the family requested 911 be called, responded that they (the family) could call 911 if they wanted. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 5 residents (Resident #1) reviewed for change in condition. On 08/10/24 around 2PM, CNA B failed to report to LVN D that CNA B observed Resident #1 had blue lips and difficulty breathing. CNA B failed to report Resident #1's change in condition to LVN D so that LVN D could reassess Resident #1. LVN D, when notified by the family that they were requesting 911 called responded that they (the family) could call 911 if they wanted. LVN D failed to re-assess Resident #1 by not checking her lung sounds, attempting the Heimlich maneuver, and staying with the Resident #1 to determine if she was choking, aspirating, or developing difficulty with chewing or swallowing. [...]

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure that the assessment accurately reflected the resident's status for 3 (Resident #5, Resident #9, and Resident #10) of 10 resident reviewed for accuracy of MDS assessment, in that: Resident #5's quarterly MDS did not accurately reflect the residents' oxygen therapy in the quarterly MDS assessment. Resident #9's quarterly MDS did not accurately reflect the residents' oxygen therapy in the in the quarterly MDS assessment. Resident #10's quarterly MDS did not accurately reflect the residents' oxygen therapy in the in the quarterly MDS assessment. This failure could affect residents at the facility who had been assessed for oxygen therapy use and could contribute to inadequate care.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 2 of 10 residents (Resident #4 and Resident #7) reviewed for care plans. The facility failed to implement a comprehensive person-centered care plan for Resident #4's history of oxygen therapy. The facility failed to implement a comprehensive person-centered care plan for Resident #7's history of oxygen therapy. This failure could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 5 (Resident #3, Resident #4, Resident #5, Resident #9, and Resident #10) of 10 residents observed for oxygen management and 6 (room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], room [ROOM NUMBER], and room [ROOM NUMBER]) of 15 rooms observed for oxygen sign postings, and 1 (Resident#5) of 5 residents reviewed for oxygen orders. Resident #3's oxygen tank was empty behind his wheelchair. Resident #4's oxygen tank behind her wheelchair in her room was empty. Resident #5's oxygen tank was on empty behind his wheelchair while he was in the dining area. Resident #9's oxygen tank was empty behind her wheelchair she was in the dining area. [...]

Inspectors wroteBased on observation, interview, 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 disease and infection for 3 (Resident #3, Resident #4, Resident #5) of 10 residents and 1 (room [ROOM NUMBER]) of 6 rooms reviewed for infection control. 1. Resident #3's nasal cannula was not stored in a zip lock bag and or baggy. 2. Resident #4's nasal cannula was not stored in a zip lock bag and or baggy. 3. Resident #5's nasal cannula was not stored in a zip lock bag and or baggy. room [ROOM NUMBER] in the restroom was a nasal cannula that was hanging in the shower area and not in zip lock bag and or baggy. These failures could place residents at risk for infection due to improper care practices. [...]

Inspectors wroteBased on interview and record review the facility failed to immediately notify and consult with the resident's physician and resident's representative when a significant change in a resident physical, mental, or psychosocial status (that was a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #2) of 4 residents reviewed for change in condition. The facility failed to immediately inform the NP/MD and the family (RP/POA) on 09/24/24 of Resident #2's change in condition addressing her fall on 09/24/24. This failure could place residents at risk of serious decrease in health related to delayed treatment.

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review program for one (Resident #10) of 3 residents reviewed for compliance with PASRR regulations. -The facility failed to submit and coordinate Resident #10's PASRR assessment and screening in the LTC Online Portal -The facility failed to refer Resident #10 for a PASRR evaluation based on mental disorder diagnoses including [NAME]-[NAME] Syndrome (genetic disorder that causes obesity, intellectual disability, and shortness in height). This failure could place residents at risk of not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs and describes the services to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 (Resident #10) of 6 residents reviewed for comprehensive care plans in that: -The facility failed to develop a comprehensive care plan for Resident #10's diagnosis of [NAME]-[NAME] syndrome. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for accidents. The facility failed to place Resident #1's bed low to the ground and place the fall mat next to the bed while Resident #1 was in bed. This led to Resident #1 on 06/22/24 having her left arm/hand caught in between the grab bars (enablers) and the mattress, her right back shoulder hit the tray table, her right arm hit the trash can, and her rear hit the ground while her legs slid underneath the bed. An Immediate Jeopardy (IJ) was identified on 07/26/24 at 4:24 PM. While the IJ was removed on 07/27/24, the facility remained out of compliance at a scope of no actual harm and a severity level of isolated because the facility was continuing to monitor its plan of removal for effectiveness. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 (Residents #1, and #2) of 4 residents reviewed for call light placement. The facility failed to ensure that Residents #1, and #2 's call lights were within their reach. This failure placed residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on interview and record review the facility failed to allow the resident to obtain a copy of the records upon request and upon two working days advance notice to the facility for 2 of 6 residents (Resident #2 and Resident #5) whose records were reviewed in that: -The facility failed to provide Resident #5's legal representative copies of medical records after a request was submitted to the facility. - The facility failed to provide Resident #2's family member a copy of the EKG report. This failure could place residents at risk of violation of their rights by not receiving copies of their medical records.

Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for two (Resident #2 and Resident #3) of six residents reviewed for physician notification. -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 7 doses of the prescribed IV antibiotics on hand to administer to Resident #2 according to physician's orders. -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 8 doses of the prescribed IV antibiotics on hand to administer to Resident #3 according to physician's orders. This failure could place residents at risk of delayed medical treatment.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Resident #1, and Resident #3) of 6 residents reviewed for accuracy of MDS assessments. - The facility failed to ensure that Resident #1's MDS accurately reflected resident had an Enteral Feeding. -The facility failed to ensure that Resident's #3's MDS accurately reflected resident had an infection to right knee. These failures could put residents at risk of not receiving the necessary care and services to prevent falls and injuries related to inaccurate MDS assessment.

Inspectors wroteBased on interviews and record reviews the facility failed to coordinate with the appropriate, State-designated authority, to ensure that individuals with a mental disorder, intellectual disability, or related conditions received care and services to meet the needs of the residents for 2 (Resident #4 and Resident #6) 2 residents reviewed for PASRR services. -The facility failed to provide Specialized Services to Resident #4 as agreed to during the interdisciplinary meeting. -The facility failed to ensure that all PSCR benefits were being provided to Resident #6. The failures could affect residents who are PASRR positive by placing them at risk of not receiving needed PASRR services which could lead to a decline in health and well-being.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for comprehensive care plans in that: The facility failed to develop a comprehensive care plan for Resident #1 after she sustained a fall on 06/22/24 that addressed the resident's skin tear and fracture to her left wrist. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and not having personalized plans developed to address their needs.

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 for 1 (Resident #1) of 1 resident observed for oxygen management. Resident #1 was on oxygen without a physician's order. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health; and place them at risk of an unsafe environment which could lead to accidents and injuries.

Inspectors wroteBased on 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 (Resident #2 and Resident #3) of 6 reviewed for medication administration in that: -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 7 doses of the prescribed IV antibiotics on hand to administer to Resident #2 according to physician's orders. -The facility failed to immediately consult with physician and/or Nurse Practitioner when the facility did not have 8 doses of the prescribed IV antibiotics on hand to administer to Resident #3 according to physician's orders. This failure put residents at risk of delayed medical treatment.

Inspectors wroteBased on interviews, and record review, the facility failed to provide laboratory services to meet the needs of its residents, for 1 of 6 (Resident #3) residents reviewed for laboratory orders. -The facility failed to ensure that labs were done on a timely basis and lab results were promptly received to prevent delay in medical treatment for and for 8 doses of the prescribed IV antibiotics on hand to administer to Resident #3 according to physician's orders. This failure could place residents at risk for untreated medical conditions and diminished quality of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 2 of 6 (Resident #1, and Resident #2) reviewed for accuracy and completeness of medical records. -The facility failed to document notification of change of condition for Resident #2 on 07/03/24. -The facility failed to ensure SBAR INTERACT Communication Form for Resident #1 did not have blanks in the documentation. -The facility failed to document in Event Report for Resident #1 injuries and mental status at time of incident on 06/22/24. -The facility failed to document an order for use of grab bars for Resident #1. -The facility failed to document for Resident #1 the type of pain and pain medication that was administered. -The facility failed to ensure Pain Evaluation dated 06/26/24 for Resident #1, was signed and dated. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include all written grievance decisions include the date the grievance was received, a summary statement of the resident's grievance, the steps taken to investigate the grievance, a summary of the pertinent findings or conclusions regarding the resident's concerns, a statement as to whether the grievance was confirmed, any corrective action or to be taken by the facility as a result of the grievance, and the date when the decision was issued for 1 of 6 (Resident #3 ) reviewed for resident rights. -The facility failed to ensure prompt resolution when Resident #3 was not administered 8 doses of the prescribed IV antibiotics according to physician's orders. These failures could place residents at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be treated with dignity and respect, to include the right to be free from physical restraints for 1 of 6 residents (Resident #1) reviewed for physical restraints. The facility failed to have medical symptoms for Resident #1 that warranted use of physical restraint; failed to have an order for use of Grab Bars on the bed; and failed to conduct on-going evaluation for use of restraint. Resident #1 sustained a fall on 06/22/24, left arm was caught between the mattress and the grab bar resulting in a left wrist fracture and contusion to right hip. This failure could place residents with restraints at risk of restricted movement, entrapment, decline in ADLs function, and psychological distress.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies that prohibit and prevent abuse for 1 of 12 employees (the Administrator) reviewed for criminal background checks. The facility failed to run the Administrator's criminal background check prior to him starting his duties on 05/13/24. This failure could place residents at risk of potential abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 1 (Resident #1) of 5 residents reviewed for enablers (bed rails/grab bars). On 06/22/24, Resident #1 fell out of bed at 12:31:04 AM - Resident #1 was noted to have an enabler (bed rail/grab bar) connected to the upper area of her bed. Resident #1's Enabler assessment dated [DATE], revealed, that it was incomplete. The digital form was not signed nor was there any input in the questions such as, Was there a risk to the resident if enablers are used? (all left blank). [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 5 (Resident # 1, 2, 3, 4, 5 and 6) of 7 residents reviewed for wound treatment of wounds, 1. Resident #1 did not receive physician-ordered wound treatment on 6 occasions: for physician's order 04/09/2024 provision of care was not documented on 04/21/2024; for physician's order 04/09/2024 through 04/24/2024 provision of care was not documented on 04/14/2024, 04/20/2024, 04/21/2024, 04/24/2024; for physician's order dated 04/09/2024 through 04/19/2024 for provision of care was not documented on 04/19/2024. 2. Resident #2 did not receive physician-ordered wound treatment on 16 occasions: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for one of four medication carts (Medication Cart 100 Hall) and four Treatment Carts (Treatment Carts in 300 hall, facility rotunda, 200 hall, 100 hall) of five Treatment carts observed for being locked when staff were absent from the area. On 05/04/2024 the 300 hall Treatment cart was unlocked and unattended. On 05/04/2024 Rotunda Treatment Cart was unlocked and unattended. On 05/04/2024 The 200 Hall Treatment Cart was unlocked and unattended. On 05/04/2024 The 100 Hall Medication Cart was unlocked and unattended. On 05/04/2024 The 100 Hall Treatment Cart was unlocked and unattended. This failure put residents at risk of unauthorized and unsupervised access to medications and medical equipment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that, in accordance with accepted professional standards and practices, the facility maintained medical records on each resident that were complete and accurately documented for four (Residents #1, #3, #4 and #6) of seven residents reviewed for documentation of provision of assistance with bathing. The CNAs software for documentation of bathing assistance was incorrectly set up at admission/readmission for Residents #1, #3, #4 and #6 so there was no documentation showing bathing assistance had been provided. This failure put residents at risk of diminished self-image, poor self-hygiene, and impaired skin integrity as a result of undetected lapses in the provision of assistance with bathing.

Inspectors wroteBased on interview and record review the facility failed to ensure that it employed a qualified social worker on a full-time basis for one of one social worker positions reviewed. The facility, which was licensed for 124 beds, failed to employ qualified social worker on a full-time basis since on 02/29/2024 This failure put facility residents at risk of not having their psychosocial or discharge planning needs met.

Inspectors wroteBased on interview and record review the facility failed to develop a baseline care plan for each resident within 48 hours of a resident's admission for one (Resident #1) of seven residents reviewed for baseline care plan. The facility failed to complete Resident #1's baseline care plan until 04/09/2024 although he was admitted on [DATE]. This failure could put residents at risk of not having their care needs met.

Inspectors wroteBased on interview and record review the facility failed to implement an effective discharge planning process that focused on the resident's discharge goals and ensured that the discharge needs of each resident are identified and result in the development of a discharge plan for each resident for one (Resident #1) of seven residents reviewed for development of a discharge plan. The facility failed to develop a discharge plan for Resident #1 who was admitted on [DATE] until the day before he was discharged on 05/07/2024. This failure increased resident's risks for not having their care needs addressed after discharge.

Inspectors wroteBased on observation, interview 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 two (Resident #4 and #7) of seven reviewed for infection prevention and control. The facility failed to ensure that Resident #4's catheter tubing and catheter drainage bag was not touching the floor on 5/4/2024. The facility failed to ensure that Resident #7's catheter tubing and catheter drainage bag was not touching the floor on 5/6/2024. This failure put residents at increased risk of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 3 of 4 residents (Resident #1, Resident #2, and Resident #4) reviewed for comprehensive care plans in that: - The facility failed to develop a comprehensive care plan for Resident #1 that addressed antiplatelet platelet medication, feeding tube, restlessness when in bed, anti-anxiety medication, hematoma to right side of head, UTI, and pneumonia. [...]

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 3 (Resident #1, Resident #2, and Resident #4) of 4 residents reviewed for neurological checks. -The facility failed to ensure Resident #1 had neurological checks done after she was found with a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to right side of forehead on 04/17/23 on the morning shift. -The facility failed to ensure Resident #2 had neurological checks done after she was found with a hematoma on the forehead on 04/05/23 on the morning shift. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for physician notification. The physician/FNP were not notified that Resident #1 was restless on 04/16/24 on the night shift and was found with her face on the air mattress pump on the foot of the bed. This failure put residents at risk of delayed medical treatment.

Inspectors wroteBased on interview and record review the facility failed to implement written policies that prohibit and abuse, neglect, and exploitation of residents and to investigate any such allegations for two (Resident #1 and Resident #2) of 4 residents reviewed for implementation of written abuse, neglect, and exploitation policies: The facility failed to follow the facility policy on reporting allegations of all alleged violations to the Administrator, State agency and other officials in accordance with state law on and to investigate any such allegations on; -04/17/24 when Resident # 1 was found with a hematoma to right side of forehead of unknown origin. -04/05/24 when Resident # 2 was found with a hematoma to ghe forehead of unknown origin. This failure could place all residents at the facility at risk for abuse.

Inspectors wroteBased observation, interviews and record reviews the facility failed to ensure all alleged violations which involved abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for 2 of 4 Residents (Residents #1, and #2) reviewed for injuries of unknown origin. 1. The facility failed to ensure staff reported to the Administrator and or the state agency on 04/17/24 when Resident #1 was found with a hematoma (a pool of mostly clotted blood that forms in an organ, tissue, or body space) to the right side of her forehead and the cause of injury was unknown. 2. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property for 2 of 4 (Resident #1 and Resident #2) reviewed for abuse and injuries of unknown origin. The facility failed to ensure Resident #1's and Resident #2's injuries of unknow origin were thoroughly investigated. This failure could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the assessment accurately reflected the resident's status for 2 (Residents #1, and Resident #4) of 4 residents reviewed for accuracy of MDS assessments. - The facility failed to ensure that Resident #1's MDS accurately reflected resident's behaviors that put her at risk for falls. -The facility failed to ensure that Resident's #3's MDS accurately reflected resident had a history fo falls and use of anti-anxiety medication. These failures could put residents at risk of not receiving the necessary care and services to prevent falls and injuries related to inaccurate MDS assessment.

Inspectors wroteBased on interview and record review the facility failed to ensure that resident assessments accurately reflected the resident's status for one (Resident #6) of nine residents reviewed for accuracy of resident assessments. The facility failed to ensure that Resident #6's MDS admission assessment accurately reflected the resident's history of falls. This failure put residents at increased risk of falling as a result of staff not being aware of their history of falling.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #9) of nine residents reviewed for quality of care. The facility failed to ensure that an unlicensed staff member did not put a bandage on Resident #9's left forearm without prior assessment by a nurse or a physician's order. This failure could put residents at risk of unassessed wounds, undocumented treatment and undiagnosed infections.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #3) of 4 residents reviewed for call light placement. The facility failed to ensure that Residents #3's call light was within reach. This failure placed residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on interview and record review the facility failed to immediately notify and consult with the resident's physician when a significant change in a resident physical, mental, or psychosocial status (that was a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) for 1 (Resident #7) of 3 residents reviewed for change in condition. The facility failed to immediately inform NP/MD on 02/12/24 of Resident #7's change in condition addressing her antibiotics that the facility did not have on hand and had to wait two days before the facility could administer her antibiotics. This failure could place residents at risk of serious decrease in health related to delayed treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for 1 (Resident #3) of 4 residents reviewed for folowing physician orders. Resident #3 was not given wound care as prescribed by physician orders. This failure could affect others by placing them at risk of potential medical complications related to changes in condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice to promote healing and prevent worsening of pressure injuries for 1 (Resident #3) of 3 residents reviewed for pressure ulcers. The facility failed to provide and assess care for Resident #3's facility acquired pressure ulcers to the left elbow in which the same Q-tip was used for two wounds in cross contaimation and to the right outer heel with pulling off the dressing without soaking to the dressing to prevent injury to Resident #3. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health.

Inspectors wroteBased on 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 1 (Resident #7) of 4 reviewed for medication administration in that: Resident #7 was not given her antibiotics according to physician's orders four times a day every day for 02/13/24, 02/14/24, and on 02/18/24, two doses at 9:00 AM and 1:00 PM . This deficient practice could result in a decline in health due to incorrect medication administration and inaccurate count of controlled medications.

Inspectors wroteBased on, interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 1 (Resident #3) of 5 residents reviewed for medical records. The Assistant Wound Care Nurse failed to ensure Resident #3's treatment administration record accurately documented treatment for the Resident #3's wound care according to physician's orders. This failure could place residents at risk of not receiving needed services.

Inspectors wroteBased on observation, interview 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 disease and infection for 1 (Resident #3) of 5 residents reviewed for infection control in that: Wound Care Nurse used the same Q-tip dipped in Med-honey to apply to two different pressure ulcers on Resident #3. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 3 (Resident #15, Resident #23, and Resident #54) of 28 residents reviewed for care plans in that: The facility failed to implement a comprehensive person-centered care plan for Resident #15 that reflected the physician ' s order for continuous tube feeding. The facility failed to implement a comprehensive person-centered care plan for Resident #23 that reflected the resident ' s diagnosis of dysphagia. [...]

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents received parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders for 2 (Resident #27 and Resident #20) of 2 residents reviewed for Midline/PICC (Peripherally Inserted Central Catheter) care. The facility failed to ensure that Resident #27's and Resident #20's midline dressing was changed according to doctor's order. This failure placed residents at risk of developing an infection.

Inspectors wroteBased on 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 one (Resident #105) of five residents reviewed for accurate administering of drugs. The facility failed to obtain physician-ordered medication for sleep apnea (Modafinil) for Resident #105 from admission until 01/11/2024. This failure placed residents at risk of inadequate therapeutic outcomes and a decline in health due to not receiving medication for sleep apnea as ordered.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #24) of 6 residents reviewed for psychotropic medication. The facility failed to ensure that Resident #24 did not receive antipsychotics (Seroquel/quetiapine and Risperdal/risperidone) that were not necessary to treat a specific condition. These failures could put residents at risk of side effects from unnecessary psychotropic medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure food was prepared in a form designed to meet individual needs for two (lunch) of two meals reviewed. The facility failed to ensure the mechanical soft lunch meals were prepared to the desired consistency. This placed residents who received mechanical soft meals from the kitchen at risk of weight loss, poor intake, choking, and aspiration.

Inspectors wroteBased on interview and record review, the facility failed to provide snacks at times outside of the scheduled meal service times and consistent with the plan of care for 1 of 39 residents reviewed for bedtime snacks. (Resident #27) The facility did not provide Resident #27 with a bedtime snack. The facility failure could place residents who received ordered bedtime snacks at risk of low blood sugar, experiencing hunger in the evening hours, weight loss, and a diminished quality of life.

Inspectors wroteBased on observation, interview 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 disease and infection for 5 of 6 unidentified residents observed during glucose checks , 1 (yellow bin) of 2 yellow bins, and 1 (laundry cart cover) of 1 laundry cart reviewed for infection control in that: 1. Failed to disinfect the glucometer between residents. 2. 1 yellow bin had its lid off exposing the linen. 3. 1 laundry cover had holes and was coming apart. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interviews and record review the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 3 (Residents #98, #101, and #431) of 10 residents reviewed for call light button placement. The facility failed to ensure that Residents #98, #101, and #431 ' s call lights were within their reach. This failure put residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on interview and record review the facility failed to have evidence that all alleged abuse violations are throroughly investigated for 1 (Resident #18) of 23 residents reviewed for employee treatment of residents. The facility failed to interview CNA P who had provided services to Resident #18 at the time abuse was alleged. This failure could put residents at increased risk of abuse or neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must be developed within 48 hours (about 2 days) of a resident's admission for 2 of 5 residents (Resident #57 and Resident #428) reviewed for baseline care plan. Resident #57 did not have a baseline care plan that addressed her focus areas of needed care. Resident #428 baseline care plan address her focused area of diabetes care. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pnecessary services to maintain good grooming for 1 of 6 residents (Resident #20) reviewed for foot care. The facility failed to provide nail care for Resident #20 . This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide proper treatment and care to maintain mobility and good foot health in accordance with professional standards of practice, including to prevent complications from the resident's medical conditions and if necessary, assist the resident in making appointments with a qualified person, and arranging for transportation to and from such appointments for 1 of 6 residents (Resident #431) reviewed for foot care. The facility failed to provide access to a podiatrist for Resident #431. This deficient practice placed residents at risk of poor foot hygiene and decline in residents' physical condition.

Inspectors wroteBased on observation, interview and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 7 medication carts reviewed for medication storage and security. Medication Cart #1. Facility failed to ensure Medication Cart #1 was secured when it was left unattended. These failures could place clients at risk for drug diversion or accidental ingestion.

Inspectors wroteBased on observation, interview and record review the facility failed to safeguard medical records against loss, destruction, or unauthorized use for 1 (medical records black box) of 1 reviewed for medical records. The facility medical records black box had resident information coming out of its slit opening exposing resident information to the public. This failure could place residents at risk of having their personal information exposed to everyone.

Inspectors wroteBased on observation, interviews and record review the facility failed an adequately equipped system allowed residents to call for staff assistance through a communication system for 1 (Resident #227) of 10 residents reviewed for call light button placement. The facility failed to ensure that Resident #227 ' s call light was functioning properly. This failure put residents at risk of not being able to call for assistance when needed.

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 in 1 of 1 kitchen reviewed for professional standards for food service safety. -1 bag of fish fillets found in freezer opened to air and outside of its original package without a label of its contents. -1 bag of garlic bread found in freezer removed from the original package that was without a label of its contents. These failures could place residents at risk of food-borne illness.

Inspectors wroteBased on interviews and record reviews, the facility failed to provide an MDS assessment that accurately reflected the resident's status for 1 of 4 residents (Resident #1) reviewed for accurate assessments in that: -The facility failed to accurately reflect Resident #1's active diagnosis of chronic obstructive pulmonary disease (COPD), and oxygen therapy on the Quarterly MDS assessment. This deficient practice could affect residents who receive MDS assessments and could cause residents not to receive correct care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice for 1 of 4 residents (Residents #8) reviewed for respiratory care in that: -The facility failed to ensure that Resident #8's humidifier for her oxygen concentrator had water. This deficient practice could affect residents who received oxygen therapy and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health.

Inspectors wroteBased on observation, interview, 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 diseases and infections for 1 of 8 residents (Resident #8) reviewed for infection control, in that, -The facility failed to ensure that staff sanitized a nasal cannula that was observed on the floor before placing the nasal cannula back on the resident. -The facility failed to ensure that staff performed hand hygiene and don gloves when in contact with Resident #8's oxygen equipment. This deficient practice had the potential to affect residents in the facility by placing them at risk of contracting, spreading and/or exposing them to pathogens that could lead to the spread of communicable diseases.