Avir at Kerrville

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of five (5) residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on her Quarterly MDS assessment, dated 04/30/2026, for having had weight loss of 18.2%, ten percent (10%) or more in the last six (6) months. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post on a daily basis information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for two (2) of two (2) days (06/30/2026 and 07/01/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information at the beginning of each shift on 06/30/2026 and 07/01/2026. These failures could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received services in the facility, 1 of 6 residents (Resident #2), reviewed for reasonable accommodation. The facility failed to ensure the call light was within reach for Resident #2, on 6/18/2026. This failure could place residents at risk of not being able to call for help as needed, not receiving care and services in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents (Resident #2) reviewed for indwelling urinary catheter care. The facility failed to ensure Resident #2's indwelling urinary catheter drainage bag was not lying on the floor. This failure could place residents with indwelling urinary catheter devices at risk for the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all 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 were stored in accordance with currently accepted professional principles for 1 of 4 medication/treatment carts reviewed for storage of drugs. The facility failed to ensure the treatment cart was locked and secured when it was left unattended. This failure could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interview and record review the facility failed to manage the personal funds of the residents deposited with the facility for 1 (Resident #3) of 5 residents reviewed for access to personal funds. The facility failed to provide Resident with personal funds upon request for at least 2 months. This deficient practice could place residents at risk for not having money to purchase personal items to meet their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 1 of 5 residents (Resident #2) reviewed for abuse. The facility failed to have evidence that a thorough investigation was conducted following the allegation regarding staff blew cigarette smoke in front of Resident #2. These failures could place residents at risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good grooming, and personal hygiene for 1 of 1 Resident (Resident #4) reviewed for showers. The facility failed to ensure Resident #4 received a shower on his scheduled shower days. This deficient practice could place residents at risk of poor hygiene and poor self-esteem.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and support for daily living safely for 1 of 4 hallways (400-hall) reviewed for safe environment. A lunch tray that had leftover food without a cover was on the furniture unattended at the 400-hallway. This failure could place residents at risk for foodborne illness or choking if some confused residents might eat the leftover food on the lunch tray.

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 1 of 8 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's diazepam for anxiety was administered on 12/13/25, 12/14/25, 12/15/25. 12/16/25, 12/19/25, 12/20/25, and 12/21/25 (total 7 days and 11 doses) because the medication was not available, and the nurses did not contact the pharmacy, physician, or DON. These failures could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were labeled in accordance with currently accepted professional principles and stored in locked compartments for 1 (400-hall nursing cart) of 3 medication carts reviewed for medication storage. The facility failed to ensure the 400-hall nursing cart was not left unlocked and unattended on 04/23/2026. These failures could place residents at risk of ingesting medications not prescribed for them or drug diversion.

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 1 of 1 kitchen reviewed for storage, preparation and sanitation. 1. The facility failed to discard hamburger burns, with a best used by date of 04/22/2026, from the kitchen cooking table on 04/23/2026. 2. The facility failed to label and date Jello stored in the refrigerator inside the facility kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food-borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for social work services. The facility failed to employ a full-time social worker for January- March 2026. This failure could result in residents' psychosocial needs not being met and diminished quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to ensure documented assessments accurately reflected the resident's status for 1 of 3 residents (Resident #1) reviewed for assessments. The facility failed to ensure the quarterly MDS submitted on 1/1/2026 for Resident #1 accurately reflected the resident's pain management in section J0100. This failure could result in improper care of residents.

Inspectors wroteBased on observations, interviews, 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, accurately documented, readily accessible, and systematically organized for four (4) of five (5) residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for clinical records. 1. The facility failed to ensure Resident #1's right thigh wound care treatments were documented in her medical record for 10 of 45 treatments (01/02/2026 during day shift, 01/03/2026 during day shift, 01/05/2026 during day shift, 01/15/2026 during day shift, 01/16/2026 at 08:00 a.m., 01/24/2026 at 08:00 a.m., 01/25/2026 at 08:00 a.m., 01/30/2026 at 08:00 a.m., 02/02/2026 at 08:00 p.m., and 02/03/2026 at 08:00 p.m.) scheduled between 01/01/2026 to 02/06/2026 (at 04:20 p.m.). 2. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the assessment accurately reflected the resident's status for one (1) of five (5) residents (Resident #1) reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on her Quarterly MDS assessment, signed as completed on 01/12/2026, for a wound that was acquired on 12/03/2025. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (1) of five (5) residents (Resident #1) reviewed for quality of care. 1. LPN D failed to complete Resident #1's wound care on 01/26/2026 per physician order and documented an exception code for resident sleeping. 2. LPN E failed to complete Resident #1's wound care on the evening shift of 02/04/2026 and 02/05/2026 per physician order. These failures could place residents at risk of not receiving necessary medical care, harm, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to post nurse staffing information data requirements on a daily basis information that included the facility name, current date, total number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care per shift to include registered nurses, licensed practical or licensed vocational nurses, certified nurse aides and the resident census for one (1) of three (3) days (02/04/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information on 02/04/2026. This failure could place residents at risk of not having access to information regarding staffing data and the facility census.

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 and failed to determine that drug records were in order and that an account of all controlled drugs was maintained for 2 of 4 residents (Resident #1 and Resident #2) reviewed for narcotic reconciliation. Resident #1 was missing narcotic medication (Tramadol) on 12/23/25. Resident #2 was missing a narcotic medication (Hydrocodone) on 12/23/25. This failure could place residents at risk for not receiving therapeutic effects of treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments and controlled drugs must be stored in separately locked, permanently affixed compartments for 1 of 1 container reviewed (Resident #3) for proper storage for destruction of narcotics. Resident #3's, a DEA controlled substance (valium), was not stored appropriately in a double locked container. This failure could place residents at risk of not receiving prescribed medications as ordered and drug diversions.

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 1 of 3 residents (Resident #1) reviewed for drug administration in that:Resident #1 was administered one tablet of Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) twice a day from 11/14/2025 to 11/26/2025. The physician order was 1 tablet of Donepezil HCL Oral Tablet 10 MG (Donepezil Hydrochloride) once a day. The noncompliance was identified as PNC. The facility had corrected the noncompliance before the survey began. This deficient practice could affect residents who receive medications by administering an incorrect dose which could cause injury to the residents.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with accepted professional standards and practices, maintain medical records on each resident that were complete and accurately documented for 6 of 8 residents (Resident #2, Resident #3, Resident #4, Resident #5, Resident #6, Resident #7). The facility failed to ensure Resident #2's treatment administration record noted wound care treatments on 12/6/2025, 12/8/2025 and 12/9/2025 as required by the orders noted on the electronic medical record. The facility failed to ensure Resident #3's treatment administration record noted wound care treatments on 12/4/2025, 12/6/2025, 12/7/25, and 12/8/2025 as required by the orders noted on the electronic medical record. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures to prohibit and prevent neglect. The facility failed to ensure that all alleged violations involving neglect were reported immediately, but not later than 2 hours after the significant medication error was discovered for 1 of 3 residents (Resident #1). The facility failed to report an injury from a medication error to HHSC when Resident #1 was noted as receiving twice the ordered daily dose of medication causing confusion and was sent to the hospital on [DATE]. This failure could place residents at risk for further neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activities professional who was licensed or registered by the State to for 72 of 72 residents reviewed for qualifications of activity professionals. The facility failed to have a qualified Activities Professional to direct their activities program. This deficient practice could place residents at risk of not receiving approaches that were individualized to match the skills, abilities, and interests/preferences of each resident for activities.

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 rights, 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 1 of 5 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan included information on required ADL care and assistance, interventions for cardiac diet, or interventions for nutritional status with a weight management plan. This failure could place residents at risk for not having their needs and preferences met.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were maintained in accordance with accepted professional standards and practices for each resident, that were complete and accurately documented for 1 of 6 residents (Residents #2[TF1] ) reviewed for accuracy of medical records. The facility failed to ensure Resident #2's progress notes were documented accurately and according to professional standards of practice when RN B documented under LVN A's profile. This deficient practice could place residents at risk for errors in care and treatment and inaccuracies in documentation.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive care plan for the 1 resident (Resident #22) reviewed for skin conditions. The facility failed to ensure Resident #22 received wound care treatment for over 30 days for his chronic skin impairment as ordered by the physician. This failure could lead to exacerbation of a resident's chronic condition, skin breakdown and injury, or infection.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, and or distributed in accordance with professional standards for food service safety, for 1 of 4 kitchen refrigerators reviewed for professional standards for food service safety, in that: The facility failed on 06/25/2025 when the produce refrigerator presented with 3 boxes, all containing 20lbs. of produce past the best by: date. This failure could place residents at risk for food borne illness.

Inspectors wroteBased on interviews and record reviews the facility failed to maintain medical records on each resident that were complete, accurately documented, readily accessible, and were systematically organized, for 2 of 8 residents (Resident #6 and Resident ##42) reviewed for accurate medical records, in that:A) Resident #6's June 2025 medication and treatment administration report (MAR and TAR) had no documentation for her prescribed:1. olodaterol and tiotropium (a combination medicine used to prevent airflow obstruction and reduce flare-ups in adults with COPD [chronic obstructive pulmonary disease] on 6/8/2025.2. Apply nystatin paste to bilateral buttocks related to rash and skin prep to the left heel (a liquid that when applied to the skin forms a protective film or barrier) on 6/17/2025.3. Change oxygen tubing and administration devices weekly on 6/15/2025.4. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure maintenance of all mechanical, electrical, and patient care equipment was in safe operating condition, for 1 of 1 facility reviewed for safe and functioning mechanical, electrical, and patient care equipment. The facility failed when the following occurred: 1. The facility's commercial electric dishwasher had a malfunctioning temperature gauge on 06/24/2025. 2. The facility did not equip 1 of 2 beds in an occupied resident room with a mattress on 06/26/2025. These failures could place residents at risk for unsafe patient care equipment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or a centralized staff work area from toilet and bathing facilities for 11 of 15 resident rooms (rooms #101, #103, #105, #107, #111, #117, #202, #210, #308, #315, and #405) reviewed for call lights. The facility failed to ensure emergency call lights in resident room bathrooms were able to be accessed and used from the floor on 06/24/2025. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

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 #27) reviewed for abuse and neglect. The facility did not report to the State Survey Agency (HHSC) an incident in which Resident #27 was slapped in the face by Resident #119 on 05/17/2025. 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 observations, interviews, and records review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 9 residents (Resident #22) reviewed for MDS accuracy. The annual MDS for Resident #22 failed to accurately document the continuous compression dressings worn by the resident. This failure could lead to residents not receiving the required care and decreased quality of life.

Inspectors wroteBased on observation, record review, and interview, 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 of care for 1 of 2 residents (Resident #61) reviewed for new admissions. The facility failed to develop a baseline care plan within 48 hours of admission for Resident #61. This failure could lead to residents not receiving necessary care and decreased quality of life.

Inspectors wroteBased on observation, record review and interview, the facility failed to ensure residents are offered a therapeutic diet when there is a nutritional problem, and the healthcare provider orders a therapeutic diet for 1 of 4 residents (Resident #20) reviewed for food and nutrition. The facility to ensure Resident #20 received nutritional supplement beverages as ordered by the physician. This failure could lead to nutritional deficits and unintended weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 8 residents (Resident #10) reviewed for medication administration. The facility provided Resident #10 with amlodipine without assessing for blood pressure as ordered by the physician. This failure could place residents at risk for not receiving the therapeutic effects of their prescribed medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles for 1 of 2 medication carts (Medication Cart for 200 hall) reviewed for storage of drugs and biologicals. The facility failed on 06/24/2025 when LVN I did not ensure the medication cart for 200 hall was locked and secured. These deficient practices could place residents at risk of medication misuse or drug diversion.

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 1 of 6 residents (Resident #14) reviewed for infection control. The facility failed to ensure staff performed proper hand hygiene and PPE utilization while performing indwelling catheter care for Resident #14. This failure could lead to infection, illness, and decreased 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 7 residents (Residents #1, #2, #3, #4, and #5) reviewed for infection control: 1. The facility failed to ensure MA-A sanitized the wrist blood pressure cuff in-between use with Residents #1 and #2 on 06/05/2025. 2. The facility failed to ensure LVN-B sanitized her hands in between feeding and assisting Residents #3, #4 and #5 with their breakfast meal on 06/05/2025. These failures could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on interviews and record review the facility failed to ensure the assessment accurately reflected the resident's status for 1 (Resident #1) of 4 residents reviewed for accuracy of assessments. The facility failed to ensure Resident #1 was coded on her Quarterly MDS assessment, signed as completed on [DATE], for a psychiatric/mood disorder, an anxiety disorder diagnosed [DATE]. This failure could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure resident medical records were kept in accordance with accepted professional standards and practices, the facility must maintain medical records on each resident that are complete and accurately documented for 2 of 4 residents (Resident #1 and Resident #2) reviewed for clinical records. 1. The facility failed to ensure Resident #1's pain status was accurately documented on [DATE] and [DATE]. 2. The facility failed to ensure Resident #1's Medication Administration Record (MAR) reflected the administration of Tylenol (medication to treat pain) was accurately documented on [DATE] and [DATE]. 3. The facility failed to ensure Resident #1's weekly skin assessments were documented in her medical record for 2 (the weeks of: [DATE] and [DATE]) of 14 weeks. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to post daily information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 4 days (05/10/2025, 05/11/2025, 05/12/2025, and 05/13/2025) of 4 days reviewed. The facility did not post the required current nurse staffing information from 05/10/2025 through 05/13/2025. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on interviews, and record reviews the facility failed to ensure personnel provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 4 (#1) residents in that: Resident #1 was administered CPR, 2 compressions which caused Resident #1 to moan in pain, by LVN A after found unresponsive. Resident #1 was a DNR. Resident #1 had an OOH-DNR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 6 PM. While the IJ was removed on [DATE] at 1:26 PM. The facility remained out of compliance at a scope of isolated and severity level of no actual harm with a potential for more than minimal harm that is not immediate jeopardy due to facility's need to evaluate the plan of removal. [...]

Inspectors wroteBased on observations interviews, and record review the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records, for 11 of 73 residents (Residents #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14) reviewed for the right to personal privacy and confidentiality of his or her personal and medical records. Medication Aide AI left a lap top computer she was assigned unattended, unsupervised, and unlocked displaying Residents #4, #5, #6, #7, #8, #9, #10, #11, #12, #13, and #14 protected health information (PHI). This failure could place residents at risk of a breach of their PHI.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to voice grievances to the facility. Such grievances include those with respect to care and treatment which has been furnished as well as that which has not been furnished, the behavior of staff and of other residents, and other concerns regarding their LTC facility stay, for 1 of 8 residents (Resident #2) reviewed for grievances. 1. On February 13, 2025, the previous Administrator and the DON heard a grievance on Resident #2's behalf and failed to initiate the grievance process. 2. On February 27, 2025, the DON heard a complaint on Resident #2's behalf and failed to initiate the grievance process. 3. On February 24,2025 the DON received a complaint via an email on behalf of Resident #2 and failed to initiate the grievance process. 4. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure all suspected violations involving abuse, neglect, exploitation, or mistreatment are reported to the state agency not later than 2 hours after the allegation is made, if the allegation does not concern abuse, for 2 of 8 residents (Residents #1, and #2) reviewed for reporting allegations of ANE. 1. On [DATE] LVN A, the ADON, the previous DON, and the Administrator at that time, failed to report an allegation of neglect on behalf of Resident #1 when LVN A performed CPR on Resident #1 while Resident #1 wished to not have CPR and had wished to be DNR status. 2. On [DATE] the previous Administrator and the DON heard an allegation of neglect on Resident #2's behalf and failed to report the allegation to the state agency. 3. [...]

Inspectors wroteBased on interviews and record reviews the facility, in response to allegations of abuse, neglect, exploitation, or mistreatment, failed to ensure all alleged violations were thoroughly investigated and reported the results of all investigations to the State Survey Agency, within 5 working days of the incident, for 2 of 8 residents (Residents #1, and #2) reviewed for investigating and reporting results to the state survey agency. 1. On [DATE] LVN A, the ADON, the previous DON, and the Administrator at that time, failed to investigate an allegation of neglect on behalf of Resident #1 when LVN A performed CPR on Resident #1 while Resident #1 wished to not have CPR and had wished to be DNR status. 2. On [DATE] the previous Administrator and the DON heard an allegation of neglect on Resident #2's behalf and failed to investigate the allegation and report the results to the state agency. 3. [...]

Inspectors wroteBased on observations and interviews, the facility failed to ensure all drugs and biologicals were in locked compartments and permitted only authorized personnel to have access, for 2 of the facility's 7 medication carts (a treatment cart and a medication cart), reviewed for security and supervision. 1. Medication Aide AI left the medication cart unattended, unsupervised, and unlocked. 2. LVN AM left the treatment cart unattended, unsupervised, and unlocked. These failures could place residents at risk for harm by unsecured medications.

Inspectors wroteBased on observations, interviews, and record reviews revealed the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety, for 1 of 1 Resident's food / snack pantry reviewed for food safety. The facility's Resident food snack pantry located on the residents hall had a refrigerator with 15 containers of food. The containers had various food safety concerns to include old, expired food available for residents' consumption. These failures could place residents at risk for harm by food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure personnel handled, stored, processed, and transported linens so as to prevent the spread of infection, for 1 of 1 laundry departments reviewed for infection prevention and control. 1. The laundry department presented with resident's clean blankets stored with soiled infectious laundry. 2. Laundry Aide AO and Laundry Aide AP donned only gloves and did not don full PPE while handling soiled infectious laundry. These failures could place residents and staff for cross-contamination of infectious diseases.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure, based on the comprehensive assessment of a resident, the resident received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the resident's choices for 1 of 5 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 received wound care on 2/22/25 as ordered by the physician for cellulitis. The noncompliance was identified as PNC. The noncompliance began on 2/22/25 and ended on 2/23/25. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of a decline in health, worsening wounds, and psychosocial harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an initial comprehensive assessment of each resident's functional capacity including the resident's needs, strengths, goals, life history, and preferences for 4 (Resident #1, Resident #2, Resident #3, and Resident #6) of 6 reviewed for assessments. 1. The MDS Coordinator failed to complete Resident #1's admission comprehensive assessment within 14 days after admission, 11/15/2024. 2. The MDS Coordinator failed to complete Resident #2's admission comprehensive assessment within 14 days after admission, 11/21/2024. 3. The MDS Coordinator failed to complete Resident #3's admission comprehensive assessment within 14 days after admission, 11/21/2024. 4. The MDS Coordinator failed to complete Resident #6's admission comprehensive assessment within 14 days after admission, 11/14/2024. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the initial comprehensive assessment accurately reflected the resident's status for 2 (Resident #4 and Resident #5) of 4 residents reviewed for accuracy of assessments. 1. The facility failed to accurately code Resident #4's bladder and bowel appliance status on her admission comprehensive assessment. 2. The facility failed to accurately code Resident #5's fall history with fracture on her admission comprehensive assessment. These failures could place residents at risk of improper or incorrect care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental 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 4 (Resident #1, Resident #4, Resident #5, Resident #6) of 4 residents reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #1, who was documented for full code status, assessed as requiring supervision or touching assistance for transfers, and had a history of falls; [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 3 (Resident #1) reviewed for respiratory care. The facility failed on 09/18/2024 when Resident #1's oxygen tubing and humidifier bottle were outdated for 2 weeks; and the humidifier bottle was empty of water dated, 9/2/24. This failure could affect residents administered oxygen and could lead to infections if the tubing and humidifier bottle are not cleaned/ or replaced as ordered by the physician.

Inspectors wroteBased on interviews, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete; and accurately documented for 1 of 5 residents (Resident #1) reviewed for completeness and accuracy: Resident #1's POC (point of care) for September 2024 did not reflect documentation of incontinent care and transfer being completed on the day shift for the dates 9/16/24 and 9/17/2024. This failure could result in the facility not documenting in the medical record residents ADL activities, experiencing accidents, injuries and/or a diminished quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 residents (Resident #1, #3, #4) of 4 residents reviewed for care plans. 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 4 residents reviewed for accidents and supervision, in that; The facility failed to ensure Resident #1 was supervised while ambulating and had interventions in place to prevent falls. Resident #1 who was admitted with a significant history of falls, had 5 documented falls at the facility from admission to discharge, 6/05/2024 date of admission, 6/09/2024, 6/12/2024 x 2 and 6/24/2024 when he fell during the night and suffered a subdural hematoma (a pool of blood between the brain and its outermost covering) and required a hospital stay in ICU. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 6/26/2024 at 3:50 PM. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure a registered nurse signed and certified that the MDS assessment was completed for 2 of 4 residents (Resident #1 and #3) reviewed for MDS completion, in that; 1. The facility failed to ensure Resident #1's admission MDS assessment was completed. 2. The facility failed to ensure Resident #3's entry admission MDS assessment was completed. These failures could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's current status.

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 1 of 4 residents (Resident #2) reviewed for pharmacy services. The facility failed to acquire and administer Resident #2's scheduled dose of oxycodone prior to rehabilitation services on 6/25/2024. This failure could place residents at risk of increased pain and poor quality of life.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service, taking into consideration resident assessments, individual plans of care, and the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment required for 1 of 1 kitchen in that: The facility failed to have a certified Dietary Manager or Registered Dietician to serve as the Director of Food and Nutrition Services. This deficient practice could place the residents who consume food prepared from the kitchen at risk of food borne illness and not receiving adequate nutrition.

Inspectors wroteBased on interview, and record review, the facility failed to be administered in a manner that enabled it to use its resources effectively and efficiently to maintain the highest practicable well-being of each resident for 1 of 1 facility reviewed for Administration. The facility failed to hire an onsite MDS Coordinator to ensure resident MDS assessments were completed accurately and timely and transmitted and comprehensive care plans were developed. This deficient practice could affect all residents and place them at risk for inaccurate, incomplete and unverified MDS assessments and incomplete care plans which could result in incomplete and inaccurate care and services.

Inspectors wroteBased on interviews and record reviews the facility failed to, within 14 days after a facility completes a resident's assessment, electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the admission assessment for 3 of 3 residents (Residents #101, #102, and #103) reviewed for MDS assessments. The facility failed to transmit the MDS withing 14 days of assessment for Resident's #101, #102, and #103. These failures placed residents at risk by not providing resident specific information for payment and quality measure purposes.

Inspectors wroteBased on record reviews and interviews the facility failed to conduct and document a facility-wide assessment to determine what resources are necessary to care for its residents competently during both day-to-day operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to complete a facility-wide assessment to determine what resources was necessary to care for its residents competently during both day-to-day operations and emergencies. This failure could place residents at risk for not receiving necessary care and services required.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure the activities program was directed by a qualified professional who is a qualified therapeutic recreation specialist or an activity professiona l for 3 of 3 residents (Residents #101, #102, and #103) reviewed for a qualified Activities Director. The facility admitted Residents #101, #102, and #103, without the services of a qualified Activities Director. This failure placed residents at risk for not receiving the serviced of a qualified Activities Director.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for pureed foods (1 of 2 diets served at the facility), in that: The facility failed to ensure the kitchen had recipes for pureed diets. These failures could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.

Inspectors wroteBased on interviews, and record reviews the facility with more than 120 beds must employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for a Social Worker. The facility did not have a full time Social Worker. This failure could place residents at risk for not receiving needed social services and place them at risk of psycho-social decline.