Avir at Gainesville

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for two of seven (Resident #1 and Resident #2) residents reviewed for physical environment. The facility failed to ensure Resident #1's and Resident #2's shower was in good working order and did not have broken tile, caved in wall and running water on 06/10/26. These failures placed residents at risk of resident restroom in an unsafe environment and a lack of a functional shower.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment, including but not limited to receiving treatment and support for daily living safely for 2 of 6 residents (Resident #3 and Resident #4) reviewed for resident rights: The facility failed to provide clean bed linens for Resident #1 and Resident #2's bed on 2/17/26. This failure could place residents at risk of exposure to infectious diseases and other unsanitary health hazards. Record review of Resident #3's face sheet dated 2/17/26 reflected she was a [AGE] year-old female with an original admission date of 5/31/25 and a readmission date of 9/28/25. Resident #3 had the following active diagnoses: [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 2 of 6 residents (Resident #1 and Resident #2) reviewed for care plans. 1. The facility failed to ensure Resident #1's comprehensive care plan was complete and reflected his need for a therapeutic diet. 2. The facility failed to ensure Resident #2's comprehensive care plan was complete and reflected her need for a therapeutic diet. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs. Record review of Resident #1's face sheet dated 2/17/26 reflected he was a [AGE] year-old male with an admission date of 1/9/26. [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to assist residents who were unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, personal and oral hygiene for 1 of 6 residents (Resident #3) reviewed for quality of life. The facility failed to groom Resident #3's facial hair on 2/17/26. The facility failed to assist Resident #3 with showers on 2/3/26 and 2/14/26. These failures could place residents at risk of exposure to infectious diseases, and affect their dignity. Record review of Resident #3's face sheet dated 2/17/26 reflected she was a [AGE] year-old female with an original admission date of 5/31/25 and a readmission date of 9/28/25. Resident #3 had the following active diagnoses: [...]

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for 2 of 6 residents (Resident #1 and Resident #2) reviewed therapeutic diets: The facility failed to provide Resident #1 with food that was consistent with his prescribed fortified food plan diet on 2/17/26. The facility failed to provide Resident #2 with food that was consistent with her prescribed Low Concentrated Sugar diet on 2/9/26 and 2/10/26. These failures could place residents at risk of declining health and significant fluctuations with their weight. Record review of Resident #1's face sheet dated 2/17/26 reflected he was a [AGE] year-old male with an admission date of 1/9/26. Resident #1 had the following active diagnoses: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment for two of 10 residents (Resident #18 and Resident #59) and four of 4 shared bathrooms (room [ROOM NUMBER] and 304, room [ROOM NUMBER] and 308, room [ROOM NUMBER] and 309, and room [ROOM NUMBER] and 312) reviewed for homelike environment. 1. The facility failed to ensure Resident #18's restroom tile around the toilet was in good working condition on 12/09/25. 2. The facility failed to ensure Resident #59's restroom toilet was working properly, and fan blower wires were not exposed in bathroom ceiling on 12/09/25. 3. The facility failed to ensure the restroom handrails were in good repair for bathrooms shared by room [ROOM NUMBER] and 304, room [ROOM NUMBER] and 308, room [ROOM NUMBER] and 309, and room [ROOM NUMBER] and 312. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to send a copy of the residents' discharge notice, prior to discharge, to the representative of the Office of the State Long-Term Care Ombudsman of the residents' transfer or discharge and the reasons for the move, for 1 of 4 residents (Resident #24) reviewed for the discharge process. Resident #24 was discharged on 10/15/2025, 11/08/2025 and 11/26/2025 without a notice to the Long-Term Care Ombudsman. This failure could place residents at risk of not knowing their rights or receiving the services of the state Long-Term Care Ombudsman.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 4 (Resident #2, Resident #3, Resident #19, and Resident #24) of ten residents reviewed for respiratory care.1. The facility failed to ensure Resident #2's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) was stored properly when not in use on 12/09/2025.2. The facility failed to ensure Resident #3's oxygen tubing was stored properly when not in use on 12/09/2025. 3. The facility failed to ensure Resident #19's suction tubing (used to keep the airway clear) was stored properly when not in use on 12/10/2025.4. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards in the facility's only kitchen. 1. The facility failed to ensure fryer was free of sediments and failed to ensure oil had been replaced. 2. Dietary [NAME] I and Dietary Aide J failed to ensure hair was covered or properly restrained during lunch meal service on 12/11/25. These failures could place residents at risk for food-borne illness and contamination

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for a resident for one (Resident #24) of five residents reviewed for care plans. The facility failed to ensure Resident 24's Comprehensive Care Plan reflected the use of oxygen therapy on 12/10/2025. This failure could place the residents at risk of not receiving the necessary care and services needed.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records that were accurate and complete in accordance with acceptable professional standards for 2 (Residents #23 and #24) of 4 residents reviewed for clinical records.1. Resident #23 had an OOH-DNR in their record that was missing information in Section B, Declaration by legal guardian, agent, or proxy on behalf of the adult person who is incompetent or otherwise incapable of communication.2. Resident #35 had an OOH-DNR in their record that the family member signed in sections they were not supposed to, the family member missed a required signature at the bottom, and the two witnesses to the family members signature did not sign until 14 days after the family member did. The facility's failure could place residents at risk for not receiving healthcare as per their or their legal representatives' wishes.

Inspectors wroteBased on interview and record review, the facility failed to designate a member of the facility's interdisciplinary team who is responsible for working with hospice representatives to coordinate care to the resident and to ensure facility obtained documentation from hospice for 1 of 2 residents (Resident #59) reviewed for hospice care. 1. The facility failed to ensure there was a designated member of the interdisciplinary team for hospice coordination of care. 2. The facility failed to ensure Resident #59's hospice election form and physician recertification of terminal illness for Resident #59 was available. These failures place residents at risk of lack of coordination of care and decrease in quality of care. [...]

Inspectors wroteBased observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #11) of five residents reviewed for infection control. The facility failed to ensure CNA G performed hand hygiene and changed gloves during Resident #11's incontinent care on 12/10/2025. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interview, and record review, the facility failed to protect a resident's right to be free from neglect for one (Resident #1) of 8 residents reviewed for resident neglect. The facility failed to ensure Resident #1 was free from neglect by RN A on 05/31/25. RN A failed to perform an assessment on 05/31/25 when Resident #1 reported he needed to go to the hospital complaining of leg pain. RN A failed to notify and follow-up to ensure Resident #1 was sent to the hospital. RN A failed to notify the physician or any licensed nurse of Resident #1 requesting to go to the hospital. RN A called 911 to report Resident #1's behavior, but RN A failed to report Resident #1 wanted to go to the hospital on [DATE]. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse and neglect were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials (including to the State Survey Agency in accordance with State law through established procedures for one, (Resident #1) of eight residents reviewed for resident neglect. The facility failed to report a potential allegation of neglect to the Abuse Coordinator when RN A failed to provide care and treatment for Resident # 1, who was in her care assignment. LVN B and CNA C were aware that RN A did not provide care to Resident #1. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure resident had a right to a dignified existence and self-determination that promotes enhancement of his or her quality of life, recognizing each resident's individuality for one of eight residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1's right to go to the hospital on [DATE] was followed by RN A. Police had to contact EMS for Resident #1 requesting to go to the hospital for a possible blood clot. The failure could place residents at risk of a loss of self-determination and dignity.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's physician when there was a significant change in the physical status for one (Resident #1) of six residents reviewed for notification of changes. RN A failed to notify the physician of Resident #1 being sent to the hospital on [DATE]. This failure could place residents at risk for not notifying the physician for a change in condition and hospitalization.

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen for 2 of 2 Dietary Staff (Dietary Aide J and Dietary Aide K) reviewed for kitchen sanitation. Dietary Aide J and K failed to wear effective hair restraints and to perform hand hygiene during lunch meal service on 09/10/24. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide maintenance services necessary to maintain an orderly and comfortable homelike environment for 3 (Resident #9, #19, and #45) of 6 residents reviewed for resident rights. The facility failed to ensure the shared bathroom sink for Resident #9, Resident #19, and Resident #45 was in working order. This failure could place residents at risk for infection and living in an unsanitary and uncomfortable environment.

Inspectors wroteBased on observations, interview and record review, the facility failed to develop and implement comprehensive person-centered care plans for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 6 of 24 (Residents #7, #28, #39, #43, #46, #50) of 24 residents reviewed for comprehensive care plans. 1. The facility failed to develop a comprehensive person-centered care plan for Resident #50. The comprehensive care plans failed to adress the specific psychotropic medications ordered by the physician, specific required ADL assistance and comfort measures and discharge goals. 2. The facility failed to develop a care plan for Resident #43 and #46's significant weight loss. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental and psychosocial well-being of each resident for three (Resident #13, #26 and #36) of 7 residents reviewed for activities. 1. The facility failed to provide individualized and group activities for Resident #13 on the secure unit who did not consistently attend group activities off the secure unit. The facility failed to ensure Resident #13 had an individualized activity care plan. 2. The facility failed to provide individualized and group activities for Resident #26 on the secure unit who did not attend the group activities off the secure unit. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents who needed respiratory care were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 (Resident #25, Resident #28, Resident #37, and Resident #253) of 6 residents reviewed for respiratory care. 1. The facility failed to obtain a Physician's order for Resident #37's continuous supplemental oxygen. 2. The facility failed to ensure Resident #25's nasal cannula, oxygen tubing and humidifier were changed out on 09/08/24 per physician orders. 3. The facility failed to ensure Resident # 28's humidifier was changed out when empty on 09/10/2024 per physician orders. 4. The facility failed to ensure Resident # 253 humidifier was changed out when empty on 09/10/2024 per physician orders. [...]

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on Saturdays and Sundays in June, July, and August 2024. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities.

Inspectors wroteBased on observation , interview and record review, the facility failed to promote and facilitate resident self- determination through support of resident choice for 1 of 7 residents (Resident #50) reviewed for resident rights. The facility failed to promote Resident #50's self-determination by not offering her an opportunity to smoke when smoke breaks occurred at the facility. This failure could place residents at risk of a decreased self-worth due to their preferences not being met.

Inspectors wroteBased on interview and record review, the facility to ensure a new resident was not admitted with a mental disorder, unless the state mental health authority determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority prior to admission, that the individual requires the level of services provided by a nursing facility and if the resident requires such level of services, whether the resident requires specialized services for one (Resident #9) of six residents reviewed for PASARR screening. The facility failed to ensure Resident #9 received a PASARR level 2 evaluation. This failure could affect residents with mental illness and place them at risk of not being assessed to receive needed services.

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plans were prepared by an IDT that included the attending physician, a registered nurse and a nurse aide with responsibility for the resident, a member of food and nutrition services staff and the participation of the resident for one of 8 residents (Resident #50) reviewed for care plan conference. The facility failed to ensure Resident #50 had a care plan conference to discuss her treatment and discharge goals. This failure could place residents at risk for not receiving adequate or individualized care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one of thirteen residents (Resident # 18) reviewed for ADLs. The facility failed to ensure Resident #18 had her facial hair removed and her nails cut. These failures could place residents who were dependent on staff for ADL care at a loss of dignity and a decreased quality of life.

Inspectors wroteBased on observations, 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, and the resident's choices for 1 (Resident #7) of 6 residents reviewed for quality of care. The facility failed to follow physician orders and perform wound treatments as ordered for Resident #7. 1. The ADON failed to discontinue the previous physician order from a xeroform dressing for Resident #7's surgical incision to the updated order for a wet to dry dressing on 07/01/2024. 2. Agency LVN D failed to notify the ADON, DON, or Physician of the conflicting orders and provided a xeroform and wet to dry dressing of Resident #7's incision site on 09/10/2024. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of one resident (Resident #4) reviewed for feeding tubes. 1. The facility failed to ensure LVN A flushed Resident #4's G-Tube with 30 cc of water prior to the medication administration per physician's orders. 2. The facility failed to ensure LVN A dissolved all the medications prior to administration through Resident #4's G-Tube. 3. The facility failed to ensure LVN A administered medications through Resident #4's G-Tube by gravity, and instead she pushed one of the medications with the plunger and syringe. 4. The facility failed to ensure LVN A clamped the tubing before it drained completely between each medication administration. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to establish and maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for three of thirteen residents (Resident #32, Resident #7, and Resident #4) reviewed for infection control. 1. The facility failed to ensure LVN A disinfected the blood pressure cuff in between blood pressure checks for Residents #32, Resident #7, and Resident #4) on 09/11/24. 2. The facility failed to ensure LVN A performed hand hygiene during medication administration and did not cross contaminate the medication for Resident #32 and Resident #7 on 09/11/24. 3. [...]

Inspectors wroteBased on observation interview and record review the facility failed to ensure prompt efforts were made to resolve grievances for 4 of 6 residents (Resident #1, Resident #2, Resident #3, Resident #4) reviewed for grievances. The facility did not ensure grievances from 06/01/2024 to 08/27/2024 were completed for Resident #1, Resident #2, Resident #3, Resident #4, who were not comfortable in their rooms due to lack of proper air conditioning (room temperatures). This deficient practice could place residents at risk of living in an uncomfortable environment leading to a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Residents #1) of six residents reviewed for pain management. 1. The facility failed to ensure Resident #1 was assessed, monitored and received effective pain management by LVN A after Resident #1 was found on the floor with indications of pain when mumbling and grumbling during transfer at time of unwitnessed fall on 02/24/24 at 12:17 AM. Resident #1 received no pain management from LVN A. 2. The facility failed to ensure Resident #1 received pain medication until after a 9 hour delay after the an unwitnessed fall. [...]

Inspectors wroteBased on interview and record review the facility failed to provide radiology or other diagnostic services to meet the needs of its residents in a timely manner for one (Resident #1) of six residents reviewed for radiology services. 1. The facility failed to ensure that a stat x-ray was completed in a timely manner for Resident #1 on 02/24/24. 2. The facility failed to follow up to get Resident #1's stat x-ray results in a timely manner on 02/24/24. Resident #1 had an unwitnessed fall on 02/24/24 at 12:17 AM and sustained an injury. LVN A failed to ensure x-ray physician order was placed stat and not routine 12 hours after the unwitnessed fall, X-ray tech was at facility to complete stat x-ray for Resident #1. 17 hours after unwitnessed incident, Resident was sent to hospital for increasing pain and x-ray results had not been received. [...]

Inspectors wroteBased on observations, interview and record review, the failed to implement their written abuse prevention policy and investigate allegations for two residents (Residents #1 and #8) of eight residents reviewed for resident abuse and one (LVN B) of three staff files reviewed for employee files. 1. The Administrator failed to follow facility policy when Resident #1 had an injury of unknown origin resulting in serious injury by not reporting the injury within the required timeframe. 2. CNA H failed to immediately report an allegation of abuse to the Administrator or DON related to Resident #8. 3. Facility failed to ensure LVN B's Criminal Background Check and EMR/NAR check were completed upon hire and in her employee file. These failures places residents at risk of abuse along with allegations of abuse identified and investigated thoroughly.

Inspectors wroteBased on observations, interview and record review, the failed to report allegations of abuse within 2 hours to HHSC for abuse allegations for two residents (Residents #1, #8 and) of 8 residents reviewed for reporting resident abuse. 1. The Administrator failed to report Resident #1's fall with serious injury within 2 hours to HHSC. 2. The facility failed to report an allegation of abuse involving Resident #8 to the appropriate State Agency immediately on 09/25/2023. These failures could place resident at risk of not having abuse, neglect, exploitation allegations reported.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean, comfortable and homelike environment for one of three halls (Hall 300) observed for daily living safely. The facility failed to ensure a shared bathroom on hall 300 was clean and sanitary for rooms [ROOM NUMBERS]. The facility failed to ensure a clean and sanitary mattress for Bed B in room [ROOM NUMBER]. This failure could place residents at risk for diminished quality of life due to the lack of unsanitary and unclean environment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop or implement a person-centered comprehensive care plan for one (Resident #2) of five residents reviewed for care plans. The facility failed to provide a comprehensive and person-centered care plan for Resident #2 about resident's behaviors and preferences. This failure puts residents at risk of not being provided personalized care and negatively impact their quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 1 resident of 8 residents (Resident #5) observed for infection control. The facility failed to ensure CNA G performed hand hygiene and changed gloves during incontinent care for Resident #5. This failure could place residents at risk for infection and cross contamination of pathogens and illness.

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident's environment remained as free of accident hazards as possible for one (Resident #8) of fourteen residents on the secure unit, 300 wing reviewed for quality of care. The facility failed to ensure several doors in the secure unit were not found to be open and able to be secured, allowing residents possible access to hazardous chemicals stored in the janitors closet of the secure wing, and an activity supplies closet. This failure could expose residents to undue harm, chemical exposure or poisoning.

Inspectors wroteBased on interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming and oral hygiene for one resident (Resident #1) of six residents reviewed for quality of life. The facility failed to ensure Resident #1 received showers per her shower schedule. This failure could place residents at risk of low self-esteem, anxiety, embarrassment, and a decline in their quality of life.

Inspectors wroteBased on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for one (Dietary [NAME] J) of two dietary staff reviewed for qualifications. 1. The facility failed to employ a qualified Dietary Manager. 2. The facility failed to ensure Dietary [NAME] J had a current food handlers license. This failure could place the residents at risk of not being provided a nutritional well-balanced diet and not have their dietary needs identified and addressed.

Inspectors wroteBased on observation, interview, and record review of the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored canned goods, had an uncompromised seal, free from dents. 2. The facility failed to ensure items in the kitchen and dry storage were labeled and stored in accordance with the professional standards for food service. 3. The facility failed to ensure that two of three refrigerators and two freezers' outsides were free from dirt, dust and dead bugs/pests. 4. The facility failed to discard items stored in reach-in refrigerator, kitchen area or dry storage that were not properly labeled or past the 'best buy', consume by or expiration dates. 5. [...]

Inspectors wroteBased on observations, interview and record review the facility failed to maintain mechanical and electrical equipment in safe operating condition for residents in one of one dining room and 300 hall reviewed for physical environment. 1. The facility failed to ensure dining room air conditioning was working properly to maintain safe and comfortable air temperatures for residents in the dining room. 2. The facility failed to ensure Residents #99 and #41 had working air conditioner in their room. 3. The facility failed to ensure resident room [ROOM NUMBER] and hall 300 had working air conditioner. The failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide comfortable and safe temperature levels for 17 residents including five residents (#8, #41, #23, #38, #99) and 12 residents in confidential group interview) reviewed for resident rights. 1. The facility failed to ensure dining room air conditioning was working properly to maintain safe and comfortable air temperatures for residents in the dining room. 2. The facility failed to ensure Residents #99 and #41 had working air conditioner in their room. The failure could place residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on Saturdays and Sundays in May to July 2023. This deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN-specific nursing activities.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two (Residents #28 and #7) of six residents reviewed for pharmacy services. 1. Agency LVN A failed to follow the manufacturer's instructions to [NAME] the Novolin R Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #28. 2. LVN B failed to follow the procedure for accurate administration of Resident #7's Flonase (corticosteroids to treat allergy's) Nasal Spray. LVN B did not ensure Resident #7 cleared his nasal passages before use. These failures placed residents at risk of not receiving therapeutic dosage of medication.

Inspectors wroteBased on interview and record review, the facility failed to ensure that the facility's medical director or his/her designee attended the QAPI meetings for one of one facility, reviewed for QAPI, in that: The facility failed to ensure the Medical Director attended QAPI meetings since 09/23/22. This failure placed residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for three (Resident #28, Resident #35, and Resident#7) of six residents and four of six staff members reviewed for infection control. 1. Agency LVN A failed to perform hand hygiene during wound care for Resident # 28. 2. CNA C and CNA D failed to perform hand hygiene after performing ADL care and mechanical lift transfer on Resident # 28 and before leaving the resident's room. 3. LVN B failed to disinfect the blood pressure cuff in between blood pressure checks for Residents #35 and Resident #7. These failures could place residents at-risk of cross contamination which could result in infections or illness.

Inspectors wroteBased on observation, interview and record review. the facility failed to provide a safe, functional, sanitary, and comfortable environment for dining room and three of four resident halls (200, 300 hall and 400 hall) reviewed for physical environment. 1. The facility failed to ensure the secure unit (300 hall) common area was maintained with floorboards in place and the wall not exposed. One of two doors in common area did not have a door sealant in place. 2. The facility failed to ensure resident room [ROOM NUMBER]'s closet ceiling was not leaking and had blackish stains on ceiling. 3. The facility failed to ensure resident rooms' 404 and 406 had a shower in working order. 4. The facility failed to ensure resident room [ROOM NUMBER] had a working air conditioner which did not leak. 5. The facility failed to ensure hall 200 overhead lights were free of dead bugs. 6. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the facility's dining room and three of four halls (Halls 200, 300 and 400) reviewed for pest control. 1. The facility failed to keep an effective pest control program to ensure dining room was free of flies, gnats and spiders. The facility failed to ensure bug zapper in dining room was serviced and not full of flies and gnat. The facility failed to ensure ice machine was free of dead gnat. 2. The facility failed to ensure hall 300 and dining area for hall 300 was free of bugs. 3. The facility failed to ensure halls 200 and 400 were free of bug activity. These failures could place residents at risk for spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one (Resident #28) of two resident reviewed for catheter care. CNA C and CNA D failed to keep Resident #28's urine catheter bag below the level of the bladder during a mechanical lift transfer. This failure could place residents at risk for urinary tract infections.