Avir at Enchanted Rock

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate administration of medications for 1 of 6 residents observed for medication administration. (Resident # 1) LVN B administered an incorrect dose of Xanax to Resident #1. This failure could place the 6 residents who received medications administered by LVN B at risk of not receiving the intended therapeutic benefit of their medications.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 5 residents (Residents #1) reviewed for accuracy of records: Nursing staff failed to document medication administration in the MAR for Resident #1 on 05/10/2026. The failure could affect residents whose records were maintained by the facility and could place the residents at risk of errors in care and treatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 8 residents (Resident #44) reviewed for supervision. The facility failed to prevent Resident #44 from going out a window without staff awareness. An Immediate Jeopardy (IJ) situation was identified on [DATE]. While the IJ was removed on [DATE], the facility remained out of compliance at a scope of isolated with the potential for more than minimal harm, due to the facility's need to evaluate the effectiveness of the corrective systems. This deficient practice could place residents at risk of other resident elopements and harm the resident with injury or death.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person centered care plan for each resident, consistent with the resident's rights that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and ensure the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being for 3 of 8 residents (Residents #42, #22 and #4) reviewed for care plans. 1. The facility failed to ensure a care plan was developed to address Resident #42's verbal suicide discussion with her caregiver. 2. The facility failed to ensure a care plan was developed to address Resident #22's discharge plans. 3. [...]

Inspectors wroteBased on interviews, observations, and record reviews, the facility failed to ensure that residents receive treatment and care in accordance with in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 2 of 2 residents (Resident #27 and Resident #52) reviewed for quality of care.1. Resident #27 was readmitted with a cervical collar (a neck brace, a medical device used to support, stabilize, and immobilize the neck and cervical spine after injury or surgery) and did not have orders to manage or maintain the cervical collar for 40 days.2. Resident #52 was admitted with a cervical collar and did not have orders to manage or maintain the cervical collar for 6 days. This deficient practice could place residents at risk of not receiving adequate care, harm, or injuries.

Inspectors wroteBased on record reviews and interviews, the facility failed to use the services of a registered professional nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility's reviewed for registered nurse (RN) services. The facility failed to have an RN on 11 dates during the period reviewed 11/1/2025 through 4/15/2026. This failure could place residents at risk of not having the services of an RN.Based on interview and record review the facility failed to ensure, except when waived, the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility's reviewed for registered nurse (RN) services. The facility failed to have an RN on 11 dates during the period reviewed from 11/1/2025 through 4/15/2026. This failure could place residents at risk of not having the services of an RN.

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 24 hours, if the events that caused the allegation did not result 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 8 residents (Resident #44) reviewed for abuse and neglect. The facility failed to report to the State Survey Agency that Resident #44 went out a window without staff awareness. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in response to allegations of abuse, neglect, exploitation, or mistreatment must have evidence that all alleged violations were thoroughly investigated for 1 of 8 residents (Resident #44) reviewed for abuse and neglect. The facility failed to investigate that Resident #44 went out a window without staff awareness. This deficient practice could place residents at risk of harm and other resident elopements.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible, for 1 of 8 residents (Resident #55) reviewed for urinary retention (the inability to fully empty the bladder, resulting in urine being held back even when the bladder feels full. It can be a sudden, painful, and dangerous inability to urinate requiring emergency care or a long-term condition with difficulty urinating or a weak stream.) Resident #55 had a need for straight in / out urinary catheterization (a flexible tube designed to drain urine from the bladder, which is inserted and removed immediately after the bladder is empty) 4 times a day and LVN Z performed the procedure late by 1 1/2 hours. [...]

Inspectors wroteBased on observations interviews, and record reviews, the facility failed to ensure that its Residents were free of any significant medication errors for 1 of 6 residents (Resident #22) reviewed for significant medication errors. On 4/15/2026 LVN G administered Resident #22's insulin, via an injection pen, and did not follow the manufactures' administration instructions. This failure could place residents at risk for not receiving the therapeutic effects of their medications. Based on observations, interviews, and record reviews, the facility failed to ensure that its residents were free of any significant medication errors for 1 of 6 residents (Resident #22) reviewed for significant medication errors. On 4/15/2026 LVN G administered Resident #22's insulin, via an injection pen, and did not follow the manufactures' administration instructions. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure- Food safety requirements. The facility must store, distribute and serve food in accordance with professional standards for food service safety for 1 of 1 (1 kitchen) in that: The nourishment room, in hall 100, had 2 food items that were open and not dated. This could affect all residents that keep food in the nutrition room and could result in food borne illness

Inspectors wroteBased on observations, interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete; accurately documented; readily accessible; and systematically organized, for 1 of 6 residents (Resident #55) reviewed for accurate records. LVN Z inaccurately documented care for Resident #55. This failure could place residents at risk for inaccurate records. Based on observations, interviews, and record reviews, in accordance with accepted professional standards and practices, the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and systematically organized for 1 of 6 residents (Resident #55) reviewed for medical records. LVN Z inaccurately documented care for Resident #55. [...]

Inspectors wroteBased on observations, and record reviews, 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 2 of 6 residents (Residents #26 and #27) reviewed for infection prevention measures. RN BB assessed Residents #26's blood sugar with a glucometer (a portable device used to measure blood sugar levels; A drop of blood obtained via a lancing device is placed on the edge of the strip which was inserted into the meter) and did not disinfect the glucometer with an appropriate blood borne pathogen (germs or infectious agents and include viruses, bacteria, fungi, and parasites) disinfectant; and then proceeded to assess Resident #27's blood sugar with the same glucometer used for Resident #26. [...]

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 3 of 7 residents (Resident #1. #2 and #3) reviewed for infection control in that: The facility failed to ensure the Activity Director utilized hand hygiene during meal service between resident contact for Residents #1, #2 and #3. This deficient practice could affect all residents and place them at risk for infection.

Inspectors wroteBased on Observation, Interview and Record Review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care for 1 of 3 (Resident #3) PASSAR services in that: The facility failed to submit a complete and accurate request for nursing facilityspecialized services in the LTC Online Portal within 20 business days after the date of IDT meeting. This failure could affect residents on PASARR services and could result in Resident not proving PASARR services.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure a process which provided pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each Resident, for 2 of 6 residents (resident #1 and Resident #2) reviewed for procedures for accurate acquiring, receiving, dispensing, and administering of all drugs, in that: 1. The facility had Resident #1's controlled medications unsecured, 3 loose, 0.25mg pills of clonazepam stored in the ADON's desk drawer separated from the narcotic count sheet. 2. The facility had Resident #2's controlled medications unsecured, a bottle of liquid Dilauded, loose in a narcotic drawer separated from the narcotic count sheet. These failures could place residents at risk for safety from medication errors.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater for 1 of 1 facility in that:The facility failed to post the Nursing Staff posting and have retention for 18 months. This failure could affect all residents and could result in resident not being aware of which staff were working for the day or not being aware of the census for the day.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 3 of 8 (Resident #21, Resident #51 and Resident #207) reviewed for baseline care plans. The facility failed to ensure a baseline care plan was completed within 48 hours from admission for Resident #21, Resident #51 and Resident #207. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 8 residents (Resident #207) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #207. This deficient practice could place residents at risk of keeping them from calling for help as needed.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents have the right to formulate an advance directive and determine the choice to receive or not receive CPR (cardiopulmonary resuscitation) for 1 of 8 residents (Resident #46) whose records were reviewed for code status. The facility failed to obtain a DNR order and complete a care plan for Resident #46 after the completion of the Texas OOHDNR dated [DATE]. This deficient practice could affect any resident who requested a DNR code status and could result in staff providing CPR for a resident who did not wish to be resuscitated.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were reported immediately, but no later than 2 hours after the allegation was made to the State Survey Agency for 1 of 8 residents (Resident #2) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #2 alleged that CNA J told her that her butt was too big. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that all allegations involving abuse, neglect, and misappropriation were investigated for 1 of 8 residents (Resident #2) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #2 alleged that CNA J told her that her behind was too large. This failure could place residents at risk for abuse/neglect and could lead to a diminished quality of life and psychosocial harm.

Inspectors wroteBased on interview and record review, the facility failed to conduct an accurate comprehensive assessment of each resident's functional capacity including the resident's needs, strengths, goals, life history and preferences for 1 of 8 Residents (Resident #44) reviewed for assessments. Resident #44's Quarterly MDS Assessment did not reflect his diagnosis of depression. This failure could place residents at risk for not receiving the care and services as needed.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that are identified in the comprehensive assessment, and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Resident #8 and #46) reviewed for care plans. 1. The facility failed to ensure Resident #46's care plan reflected that the resident was a DNR. 2. Resident #8 was prescribed a thoracic-lumbar-sacral orthoses (TLSO) back brace, to be worn daily and it was not reflected in the care plan. This deficient practice places residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were free from significant medication errors for 2 of 8 residents (Residents #2, and #6) reviewed for significant medication errors. 1. On 2/10/2025 at 1:37 PM, LVN O administered Resident #2's Baclofen late by 32 minutes. 2. On 2/10/2025 LVN O administered Resident #6's: a. Hydrocodone at 12:10 PM; late by 3 hours and 10 minutes. b. Cipro at 12:10 PM; late by 2 hours and 10 minutes. c. Hydrocodone at 2:10 PM; late by 1 hour and 25 minutes These deficient practices placed residents at risk for not receiving the therapeutic effects of their prescribed medications.

Inspectors wroteBased on observations, interviews, and record reviews, 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, which must include, at a minimum, standard and transmission-based precautions to be followed to prevent spread of infections, for 1 of 2 residents reviewed (Residents #23) for infection control and prevention. On 2/12/2025, CNA L provided catheter care for Resident #23 without donning Enhanced Barrier Precautions Personal Protection Equipment (EBP PPE). This failure could place residents at risk for harm by cross-contamination.

Inspectors wroteBased on interviews, observations, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 26 residents (Resident #1, #2, and #3) reviewed for accidents and hazards supervision, in that: 1. Resident #1 was found in in another town about an hour's drive from the facility. 2. Resident #2 was spotted going down looking (sic) at cars outside of the facility and had not been supervised the whole time she was outside of the facility. There were no assessments (to include skin assessments) done for Resident #2. 3. Resident #3 eloped and was found walking down the street. Resident #3 had a wander guard but nursing staff did not hear any door alarm with this exit. An IJ was identified on 01/16/25 at 04:45 PM, The IJ template was provided to the facility on [DATE] at 05:45 PM. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, that include measurable objectives and time frames to meet residents' mental, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 16 of 26 residents (Residents #11-#26) reviewed for care plans, in that. Resident #11 through Resident #26 were at high risk for elopement after completing their respective Elopement Risk Assessment and their care plans were not updated to reflect this finding per facility policy and interviews. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made for 2 (Resident #1 and #2) of 26 residents reviewed for reporting of alleged violations, in that: The facility failed to report to the state agency: 1. an elopement incident regarding Resident #1, after he had taken a car that did not belong to him from the nursing home parking lot and drove to a town over 60 miles away . 2. an incident involving a missing resident (Resident #2). This failure could place facility residents at risk of harm due to delays in reporting allegations of abuse and neglect.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as is possible; and each resident received assistance devices to prevent accidents for 1 of 3 Residents (Resident #1) whose records were reviewed for falls. Nursing staff failed to ensure both brakes on Resident #1's wheelchair were locked while not in use and that Resident #1's call light was in place per Resident #1's Care Plan. These deficient practices could affect any resident at risk for falls and could contribute to a decline in resident's physical health.

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent abuse for 1 of 24 residents (Resident #21) reviewed for abuse and neglect, in that: The facility failed to implement their policy to report and investigate Resident #21's 11/21/23 fall with a serious injury, per [state agency] guideline. The Administrator, DON, and LVN D did not report Resident #21's fall with a fracture to the state agency. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility's need to evaluate the effectiveness of their corrective actions. [...]

Inspectors wroteBased on nterview and record review the facility failed to immediately investigate, protect the resident, and report allegations of neglect when: Resident #21 had an unwitnessed fall with a serious injury on 11/21/23, per [state agency] guideline. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. While the IJ was removed on 01/13/2024 at 06:25 PM, the facility remained out of compliance at a scope of isolated with potential for more than minimal harm that is not immediate jeopardy due to the facility ' s need to evaluate the effectiveness of their corrective actions. This deficiency could have placed resident at risk for harm by abuse, neglect, and or mistreatment, contributing to further serious injuries.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure, based on the comprehensive assessment of residents, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 24 residents (Resident #21) reviewed for quality of care, in that: The facility failed to ensure Resident #21 received appropriate assessments and interventions due to being at high risk for falls. The facility failed to develop Resident #21's care plan to address interventions for risk of falls. Resident #21 had a fall on 11/21/2023 which resulted in an emergency hospitalization for a hip fracture and was admitted to the facility without any interventions for Resident #21's high fall risk. An Immediate Jeopardy (IJ) was identified on 01/12/2024 at 07:14 PM. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the resident could receive care and services safely and that the physical layout of the facility maximizes resident independence and did not pose a safety risk and received housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 3 of 48 residents (Resident #29, #58, and #36) and 1 of 1 facility's reviewed for a safe, clean, homelike environment, in that: 1. The facility failed to maintain Resident #36's room, a Resident with legal blindness, in a safe, clean, well - lit and, homelike environment. 2. The facility failed to ensure the 100 / 200-hall shower room had a functioning heater. 3. The facility failed to appropriately store an oxygen cylinder which was covered with towels in Resident 58's room. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for 1 of 24 residents (Resident #21) reviewed for comprehensive care plans, in that: Resident #21's care plan did not address that the resident was at the high risk for falls. This deficient practice could result in a loss of quality of life due to residents receiving improper care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary 1 of 24 residents (Resident #16), reviewed for care plan revisions, in that: Resident #16 had healed pressure areas that were not being marked as resolved in her care plans. These failures could place residents at risk for lack of coordination of services.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure its medication error rates were not 5% or greater. The facility had a medication error rate of 12%, based on three errors out of 25 opportunities which involved 3 of 6 residents (Resident #53, #63, and #70) observed during medication administration reviewed for medication errors . 1. LVN J failed to administer Resident #53's 8:00 AM scheduled dose of intravenous (in the vein) cefazolin (an antibiotic - works by killing bacteria or preventing their growth). 2. Medication Aide CC failed to administer Resident #70's 7:00 AM metformin (a diabetes control medication) timely, according to physician orders and instead administered the medication at 9:10 AM. 3. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure Residents are free of any significant medication errors, for 5 of 24 residents (Residents #7, #27, #43, #52 and #225) reviewed for significant medication errors, in that: 1. Medication Aide DD administered late medications to: a. Resident #7 was ordered Acetaminophen 325mg [pain reliever] and duloxetine 60mg [an antidepressant] to be administered twice a day with the first dose administered at 09:00 AM and was administered at 10:35 AM. b. Resident #27 was ordered pilocarpine ophthalmic solution [eye drops] and dorzolamide - timolol ophthalmic solution [eye drops] for glaucoma [a group of eye diseases that can cause vision loss and blindness by damaging a nerve in the back of your eye called the optic nerve] twice a day, anytime from 06:00 AM to 10:00 AM with the first dose administered at 11:05 AM. c. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store and label Drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date, for 1 of 4 medication carts, reviewed for insulin injection pens. The facility failed to label Resident #15's insulin injection pen with the dates to identify when the insulin injection pen was taken out of refrigeration storage and the date to indicate when the insulin injection pen should be discarded. This failure could place residents at risk for harm by receiving ineffective insulin therapy.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen, reviewed for kitchen sanitation, in that: The facility failed to ensure that sanitizing buckets were not near containers of food. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area from each resident's bedside, for 3 of 70 Residents (Resident #1 #41 and Resident #226) reviewed for the ability to call for staff, in that: The facility failed to provide Residents #1, #41 and #226 functioning nurse call light systems. This failure could place residents at risk for injury and diminished self-esteem, due to the inability to call for assistance.

Inspectors wroteBased on interview and record review the facility failed to immediately consult with the resident's physician and notify, consistent with his or her authority, the resident representative when there was an accident, and it had the potential for requiring physician intervention for 1 of 24 Residents (Resident #21) whose records were reviewed for accidents, in that: LVN D failed to notify Resident #21's physician when the resident had a fall on 11/21/23. This failure could contribute to residents not receiving the medical care and treatment needed and a decline in physical condition.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents' rights to voice grievances to the facility or other agencies or entities that heard grievances without discrimination or reprisal and without fear of discrimination or reprisal for 1 of 24 residents (Resident #22) reviewed for grievances, in that; 1. The facility failed to ensure CNA X, LVN J, and ADON E initiated a grievance report on behalf of Resident #22 when the Resident reported a grievance to CNA X. This failure could place residents at risk by denying their right to make and have grievances heard and contributed to feelings of not being heard and unresolved issues.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials, including to the State Survey Agency, for 1 of 24 residents (Resident #21) reviewed for abuse and neglect, in that: LVN D did not report Resident #21's fall immediately to the DON and the Administrator. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers for 1 of 24 residents (Resident #8) reviewed for prevention of pressure ulcers, in that: The facility failed to follow physicians' orders for Resident #8's ordered pressure ulcer preventions. This failure could place residents at risk for pressure ulcer development.

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, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 24 residents (Resident #58) reviewed for respiratory care, in that: The facility failed to ensure Resident #58's oxygen tank was stored and handled properly. This deficient practice could place residents at risk for danger, including decline in health.

Inspectors wroteBased on observations, interviews, and record reviews 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. The facility failed to ensure standard and transmission-based precautions were followed to prevent the spread of infections to include hand hygiene procedures were followed by staff involved in direct resident contact, for 2 of 24 residents (Residents #53 and #38) reviewed for infection control, in that: 1. LVN J did not perform hand hygiene in between, dirty to clean and in between glove changes while preparing and administering Resident #53's intravenous antibiotic medication. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that recipes were followed for 2 of 2 pureed food side items for 1/11/24 lunch, in that: 1. The facility failed to ensure that the recipes for Cabbage Cooked Pureed Thick and Beans Baked (no bacon) Pureed Thick, were being followed. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.