Avir at Lubbock

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed on 01/28/26 to seal food stored in the dry storage and food stored in the refrigerator. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to follow their own established smoking policy for 3 of 11 residents reviewed for smoking. (Residents #25, #43, #49)The facility failed to follow smoking policy for Residents #25, #43, #49. This failure could place residents at risk of smoking while unsupervised.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the reasonable accommodation of resident needs and preferences for 1 of 22 residents (Resident #6) reviewed for call light placement. The facility failed to ensure the resident call light system was within reach for Resident #6 on 05/14/2026 and 05/15/2026. This failure could place residents at risk of not receiving the necessary assistance they need to maintain their highest level of independence.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 24 residents hand sinks (room [ROOM NUMBER] and room [ROOM NUMBER]) in that: The facility failed to ensure the hot water in the hand sink in room [ROOM NUMBER] was at a comfortable temperature. The facility failed to ensure the hot and cold water in the hand sink in room [ROOM NUMBER] was functioning properly. These failures could lead to residents experiencing a diminished quality of life and a lack of home-like environment and/or comfort.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 1 of 24 residents (Resident #10) reviewed for PASRR screening, in that:Resident #10 did not have an accurate and updated PASRR Level 1 assessment, reflecting a diagnosis of mental illness. This failure could place residents, with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation, at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observations, 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, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 2 of 24 residents (Resident #12 and Resident #39) reviewed for care plans. The facility failed to develop an accurate, consistent, and completed care plan for Resident #12, specific to Resident #12's dietary needs ordered by the physician. The facility failed to develop an accurate, consistent, and completed care plan for Resident #39, specific to Resident #39's PASRR needs and services. This failure could place residents at risk of not receiving the care required to meet their individualized needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of residents for 1 (Resident #11) of 22 residents reviewed for weight assessment. The facility failed to follow physician orders for weekly weights for Resident #11. This failure placed residents at risk of weight loss and overall decline in health. Record review of the admission record for Resident #11, dated 05/14/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 22 residents (Resident #6) reviewed for infection control. 1. The facility failed to store oxygen nasal cannula off the floor.2. CNA E failed to replace nasal cannula after finding it on the floor. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 2 of 2 medication carts (Station 1 medication cart and Station 2 medication cart), reviewed for medication storage. 1. The medication cart assigned to Station 1 contained two loose pills.2. The medication cart assigned to Station 2 contained four loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions.1. On 05/14/26 at 11:03 AM an observation of the medication cart for Station 1 was conducted with MA A. Two loose pills were found in drawer of the medication cart. MA A placed the pills in a dispensing cup and took them to the DON for identification. The DON identified the medication as Carbidopa-Levodopa 25-100 (1 tablet) and Zofran 4mg (1 tablet). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse and neglect for two of five residents (Resident #1, Resident #2) reviewed for abuse and neglect. The facility failed to ensure a safe environment free from sexual abuse when Resident #2, who had a history of inappropriate sexual behaviors, placed her hand inside Resident #1's panties. The facility's DON failed to implement interventions upon Resident #2's admission on [DATE], when LVN F informed him Resident #2 was masturbating, and after Resident #2 inappropriately touched him on his pants. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for two of five residents (Resident #1, Resident #2) reviewed for abuse, neglect, and exploitation. The facility failed to implement their policies and procedures for identifying and addressing at admission Resident #2's history of inappropriate sexual behavior to prevent Resident #2, from placing her hand inside Resident #1's pantie. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents and/or hazards as possible for 2 of 5 residents (Resident #1, Resident #2) reviewed for supervision. The facility failed to ensure Resident #1, and Resident #2 received supervision to prevent Resident #2, who had a history of sexual behaviors, from sexually abusing Resident #1, when she put her hand in her panties. Resident #1 was on one to one (1:1) supervision due to a previous incident of aggression with a different resident; however, she was allowed to alone in her room with Resident #2. The Immediate Jeopardy (IJ) was identified on 09/04/25 at 6:18 PM. The IJ template was provided to the facility's Administrator and DON on 09/04/25 at 6:18 PM. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure each resident drug records were in order and that an account of all controlled drugs were maintained and periodically reconciled for 1 of 12 residents (Resident #3) reviewed for pharmacy services. The facility failed to monitor, review and reconcile Resident #3 medication administration record from on 8/21/25 which resulted in an official unknown count of (Hydrocodone) to be unaccounted for. This failure could places at an increased risk of drug diversion and misuse of resident medications or possibly make resident medication unavailable to meet their clinical needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 3 of 5 medication carts (1 nurses medication cart for memory care on Station 2, 1 nurses medication cart for Station 2 and 1 medication aide cart for Station 1), reviewed for medication storage. The facility failed to maintain proper medication storage after the following was found:The nurse medication cart located on Station 2 contained medication Lorazepam (2MG/ML; dated 8/11/25) that required refrigeration for Resident #4. The nurse's medication cart for Memory care located on Station 2 contained medication (2MG/ML; dated 8/03/25) that required refrigeration for Resident #6. The medication aide cart for Station 1 contained medication Lorazepam (unable to see the dose) that required refrigeration for Resident #5. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to review and revise resident's comprehensive care plans by the interdisciplinary team after each assessment for 1 (Resident #8) of 12 residents reviewed for comprehensive care plans. The facility failed to update or add interventions to Resident #8's care plan regarding aggressive and physical behaviors toward other residents that occurred on 08/05/25 and 08/29/25. These failures could result in residents not receiving the care that they need. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen be free from unnecessary drugs without adequate indications for its use for 2 of 12 (Resident #4 and Resident #6) reviewed for unnecessary medications. The facility failed to ensure that Resident #4 PRN orders for psychotropic drugs (Lorazepam (2MG/ML) were limited to 14 days and or provide a physician's rationale indicating that it was appropriate for the PRN order to exceed the 14 day stop date. The facility failed to ensure that Resident #6 PRN orders for psychotropic drugs (Lorazepam (2MG/ML) were limited to 14 days and or provide a physician's rationale indicating that it was appropriate for the PRN order to exceed the 14 day stop date. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide ADL (Activities of Daily Living) care to a resident who is unable to carry out activities of daily living and receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 5 residents (Resident#1, #2, and #3) observed for ADL care to ensure they were receiving appropriate hygiene in that: The facility failed to provide showers for Residents #1, #2, and #3 on their scheduled shower days. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that its medication error rate was less than 5 percent. The facility had a medication error rate of 9.38% based on 3 errors out of 32 opportunities, which involved 2 of 7 residents (Resident #6 and Resident #10) reviewed for medication administration. 1. LVN A failed to administer Resident #6's Certizine medication according to physician orders, resulting in Resident #6 receiving the medication late. 2. LVN A failed to verify the dosage on Resident #6's Simethicone 125 mg medication order prior to administering the medication, resulting in Resident #6 being underdosed. 3. LVN A failed to verify the dosage on Resident #10's vitamin D3 125 mcg medication order prior to administering the medication, resulting in Resident #10 being underdosed. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, attractive and at a safe and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable, attractive and at appetizing temperatures for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (03/12/2025 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 7 of 12 residents (Residents #3, #28, #46, #40, #62, #6 and #10) reviewed for infection control. 1. MA A failed to sanitize the blood pressure cuff between resident use for Resident #3 and Resident #28. 2. LVN B failed to utilize hand hygiene between glove changes during wound care on Residents #46, #40, and #62. 3. LVN B failed to utilize enhanced barrier precautions during wound care for Residents #46, #40 and #62. 4. LVN A failed to utilize hand hygiene between residents during medication administration for Resident #6 and Resident #10. [...]

Inspectors wroteBased on interview and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 2 of 24 resident reviewed for resident rights. (Resident #40 and Resident #32) 1. The facility failed to obtain consent from Resident #40 or the responsible party for Lorazepam (medication used to treat anxiety disorders). 2. The facility failed to obtain consent from Resident #32 or the responsible party for Lorazepam (medication used to treat anxiety disorders). This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects.

Inspectors wroteBased on interview and record reviews the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days for 2 of 24 residents reviewed for unnecessary medications (Resident #40 and #32). 1. The facility failed to ensure a PRN order for Lorazepam (medication used to treat anxiety disorders) dated 11/28/2024 and Lorazepam (medication used to treat anxiety disorders) dated 12/18/2024 had a stop date to ensure the medication did not extend beyond 14 days for Resident #40. 2. The facility failed to ensure a PRN order for Lorazepam (medication used to treat anxiety disorders) dated 12/16/2024 had a stop date to ensure the medication did not extend beyond 14 days for Resident #32. This failure placed residents with PRN psychotropic drugs at risk for side effects of psychotropic drugs and placed residents at risk for receiving unnecessary medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 2 of 4 medication carts (Station 1 medication cart and Station 2 medication cart), reviewed for medication storage. The medication cart assigned to Station 1 contained loose pills. The medication cart assigned to Station 2 contained loose pills. This failure could place residents at risk of not receiving prescribed medications as ordered and place the facility at risk of drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure foods were processed and pureed under sanitary conditions. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 facility observed for pest control. 1. The facility failed to follow the instructions from the pest control company to have multiple holes fixed in the facility that rodents potentially used for access into the building between 1/10/2025 and 2/25/2025. The noncompliance was identified as PNC . The noncompliance began on 1/10/2025and ended on 3/3/2025. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk for the spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain medical records on each resident that are complete and accurately documented for 1 of 5 residents (Resident #1) reviewed for ADL care in that: 1. The facility failed to accurately document ADL services for Resident #1. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, it was determined the facility failed to provide ADL (Activities of Daily Living) care for 7 of 7 residents (Resident#1, #10, #11, #12, #13, #14, and #15)) observed for ADL care to ensure they were receiving appropriate hygiene in that: The facility failed to provide showers for Residents #1, #10, #11, #12, #13, #14, and #15, on a routine basis. This failure could place the residents at risk of not receiving the care and services to maintain their highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal medical records for 1 of 1 resident was reviewed for privacy (Resident #8). 1. LVN B left Resident #8's information up on the screen while her computer cart was on the other side of the nurse's station, and she was at the nurse's station. The computer screen was left up with Resident #8's information up and residents were walking by, putting Resident #8's information at risk. This failure could place residents at risk of having medical information exposed to others and misuse of personal information. Findings Included: Resident #8: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the rights of the residents to be free from abuse and neglect for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse A. The facility failed to keep Resident #2 safe from abuse when Resident #1 pulled her out of bed after already exhibiting increased aggressive behavior on 11/14/24. B. The facility failed to keep Resident #3 safe from abuse when Resident #1 grabbed her in the face after already exhibiting increased aggressive behavior on 11/14/24. C. The facility failed to keep Resident #1 safe from an unknown nighttime staff when allegations of abuse was made on 11/23/24 by Resident #1 and Family Member M to CNA A, C, the Assistant Activity Director, LVN B and a confidential individual. An Immediate Jeopardy (IJ) was identified on 11/27/24 at 12:49 PM. [...]

Inspectors wroteBased on interviews and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and neglect for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. A. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC and documenting his investigation/prevention measures regarding Resident #1 by an unknown nighttime staff on 11/23/24 . CNA A, C, the Assistant Activity Director, LVN B, and a confidential individual failed to follow the facility's abuse policy by not reporting the allegation of abuse involving Resident #1, reported by Resident #1 and Family Member M on 11/23/24 to the abuse preventionist between the dates of 11/23/24-11/27/24. B. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours if the alleged violation involved abuse or neglect and resulted in bodily injury, to other officials (including the State Agency) and the Abuse Coordinator for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. A. The ADM failed to follow the facility's abuse policy by not reporting the allegation of abuse to HHSC regarding Resident #1 being hit by an unknown nighttime staff on 11/23/24. B. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated for 3 of 6 residents (Resident #1, #2, and #3) reviewed for abuse. A. The ADM failed to investigate Resident #1's allegation of abuse made against an unknown nighttime staff on 11/23/24. B. The ADM failed to investigate a resident to resident altercation (Resident #1 attempting to pull Resident #2 out of bed) that occurred on 11/14/24. C. The ADM failed to investigate a resident-to-resident altercation (Resident #1 grabbed Resident #3 in the face) that occurred on 11/14/24. These failures could place residents as risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 10 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to ensure Resident #1's care plan (problem, goal, and approach) was updated to reflect his increasingly ongoing incident of physical and verbal aggressive behaviors. This failure could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observations, interviews, 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 1 of 3 residents (Resident #1) reviewed for pain management. The facility failed to ensure Resident #1 received Hydrocodone-Acetaminophen-Schedule III 300-30 mg tablet every 6 hours-as needed (PRN) for pain on 10/30/24 from 6 A.M. to 1:50 P.M. This failure placed the resident at risk of increased pain and decreased quality of life.

Inspectors wroteBased on Interviews and record review, the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse and neglect for 1 of 6 residents reviewed for abuse. A. The ADM failed to follow the facility's abuse policy when Resident #1 reported allegations of abuse involving Resident #2 on an unknown date. B. The ADON failed to follow the facility's abuse policy when CNA A reported that Resident #1 alleged that CNA A was involved in abusing Resident #2 on 09/26/24. This failure could place residents as risk for abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or result in serious bodily injury to the administer of the facility and to other officials including the State Survey Agency in accordance with State law through established procedures for 2 of 6 residents (Residents #1 & 2) reviewed for abuse and neglect. A. The ADM failed to report an allegation of abuse involving Resident #2 that was reported to him on an unknown date by Resident #1. B. The ADON failed to report an allegation of abuse involving Resident #2 that was reported to him by CNA A on 09/26/24. [...]

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent resident abuse for 1 of 5 residents (Resident #1) of five residents whose records were reviewed for abuse. Facility staff did not implement facility policy and immediately notify administration when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an allegation of abuse was reported immediately but not later than 24 hours after the allegation was made for 1 of 5 residents (Resident #1) reviewed for reporting. The facility failed to ensure staff immediately reported an allegation of when FM #1 reported on 6/23/24 to LVN A that CNA B was rough with Resident #1 during a transfer. This failure could affect residents by placing them at risk of abuse if the reportable allegations are not reported timely after they are discovered.

Inspectors wroteBased on interview and record review, the facility failed to implement a comprehensive care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident # 2) of 8 Residents reviewed for comprehensive care plans. - The facility failed to identify and develop an intervention for Resident #2's behaviors of exposing his penis and urinating on the floor in the unit in Resident #2's comprehensive person-centered care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide sufficient nursing staff with the appropriate competencies and skills sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 2 of 8 residents (Resident #2, Resident #3) reviewed for staffing. The facility failed to have sufficient nursing staff in the memory care unit to provide supervision to assure resident safety. This failure could place residents at risk for not having their physical, mental, and psychosocial well-being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who displays or is diagnosed with mental disorder or psychosocial adjustment difficulty, received appropriate treatment and services to correct the assessed problem or to attain the highest practicable mental and psychosocial well-being, for 1 of 1 resident (Resident #63) reviewed for mental health services, in that: The facility failed to administer a dose of Resident #63's Risperidone (antipsychotic used for bipolar and schizophrenic disorder) for a week. There were behavior changes as consequences to the medication being discontinued. This failure affected one resident and placed resident at risk of emotional distress, negative behavior changes, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to ensure foods were processed, stored, and pureed under sanitary conditions. 2) The facility failed to ensure food and non-food contact surfaces were clean. 3) The facility failed to ensure staff stored personal items in a manner that prevented contamination. 4) The facility failed to ensure food was accurately dated and labeled. 5) The facility failed to protect foods from potential contamination. 6) The facility failed to ensure staff wore hair restraints in food areas. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 6 of 22 resident rooms (2, 7, 8 ,9, 47, and 49) and 2 of 4 baths (Station 1 - Bath #1 and #2) , reviewed for environment. 1)The facility failed to ensure resident use equipment were safe and in good repair (Rooms 2, 7, 8, 9 and Station 1 - Bath #1 and #2). 2)The failed to ensure rooms #47 and #49 had running water available in the sinks in their rooms 3)The facility failed to ensure room [ROOM NUMBER] had an operating air conditioner/heater unit in the room. [...]

Inspectors wroteBased on record review and interviews, the facility failed to develop a comprehensive care plan to meet the highest practicable physical, mental, psychosocial well-being for two of 22 residents (Residents #18 and #69) reviewed for care plans. 1. The facility failed to develop a care plan for Resident #18 regarding dialysis. 2. The facility failed to develop a care plan for Resident #69 regarding insulin for treatment of the diagnosis of diabetes. These failures could place residents at risk of not receiving the care required to meet their individualized needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 2 of 22 residents reviewed for medications (#11 and #18 ). 1)The facility failed to accurately acquire and administer medications as ordered for two residents (Residents #11 and #18). Resident #11 missed doses of ordered Plavix (antiplatelet medication) and Resident #18 missed doses of hydralazine (blood pressure medication) and hydrocortisone eye ointment (anti-inflammatory medication). These failures could place residents at risk of experiencing missed medications which could result in the exacerbation of their medical conditions and a decline in health status.

Inspectors wroteBased on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 1 resident reviewed for medication errors ( Resident #11). The facility failed to restart Resident #11's physician's ordered Plavix after a dental appointment. The resident was without her Plavix (blood thinner to treat stroke, heart attack, and other heart related disorders), for approximately 10 months (2/22/23 thru 12/19/23). This failure could result in residents having risk of heart attacks, strokes, blood clots, and risk of hospitalizations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly in the cart for 1 of 2 medication carts (med cart on South Hall). MA B had loose pills in the medication cart assigned to her on South Hall. 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 ensure menus were followed for 8 of 24 residents (Residents #4, 32, 35, 51, 67, 69, 70 and 75) reviewed during mealtimes. The facility failed to ensure Residents #4, 32, 35, 51, 67, 69, 70 and 75 received their meals according to the menu for 2 of 3 food forms (mechanical soft and puree) This failure could place residents at risk for unwanted weight loss and hunger.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable, and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Pureed) at 1 of 1 meal observed (1/8/24 lunch). These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 of 22 residents (Residents #43) reviewed for advance directives. 1. Resident #43's Out-of-Hospital Do Not Resuscitate (OOH-DNR) and physician orders were not consistent. This failure could place residents at risk for not having their end of life wishes honored and incomplete records.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive plan must be prepared by an interdisciplinary team to the extent practicable, the participation of the resident and the resident's representative(s)of the care plan conference for 2 of 22 residents (Resident #33 and Resident #43) reviewed for comprehensive resident centered care plans. The facility failed to invite Resident #33 and Resident #43 or the representatives to attend their care plan conferences. These failures placed the residents at risk for unmet care needs and a decreased quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure, at the time of discharge, the communication of necessary information for a safe transition of care home for 1 of 1 (Resident #81) records reviewed for discharge planning. The facility failed to provide an accurate and complete plan of care for 1 of 3 closed records (Resident #43) with plans of services for home, a list of medications in laymen's terms submitted, or a sign receipt of plan of care. This failure has the potential to affect all residents and places them at risk of not receiving appropriate resources once discharged home.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received, and the facility provided food prepared in a form designed to meet individual needs for 1 of 3 meals (2/06/24 - Supper) observed for 2 of 2 residents with orders for puréed and mechanical soft diets (Residents #32 and #75). The facility failed to provide food that was in a form to meet resident needs, 1 of 3 meals observed (2/06/24 - Supper) for 2 of 2 residents with orders for puréed diets (Resident #75) and mechanical soft diets (Resident #32). This failure could place residents at risk of decreased food intake and choking.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection control program designed to provide a safe, comfortable and sanitary environment to help prevent the development and transmission of diseases for 2 of 3 (Residents #66 an #73) and 2 of 2 (ADON B AND LVN C) staff reviewed for infection control. 1. ADON B failed to perform hand hygiene between glove changes when providing wound care for Resident #66 2. LVN C failed to perform hand hygiene between glove changes when providing wound care for Resident #73. 3. LVN C failed to keep dirty and clean supplies separated when providing wound care for Resident # 73. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on observation, interview and/or record review the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of new pressure ulcers/injuries for 2 of 3 residents (Resident #1 and Resident #2) reviewed for pressure injuries, in that: 1. LVN A failed to implement proper wound care techniques and implement adequate infection control practices to promote wound healing during observation of wound care on 11/29/2023. 2. LVN A failed to follow orders for wounds for providing wound care for Resident #1 and Resident #2, leaving wounds open to air and exposed to bacteria and possible infection. 3. Facility staff failed to treat and cover wounds for Resident #1 and Resident #2 4. [...]

Inspectors wroteBased on interviews, observation and record review, the facility failed to ensure all residents were treated with respect and dignity for 2 of 5 residents (Resident # 4 and Resident # 5) reviewed for dignity. CNA N made a video of Resident #5 yelling and cussing and posted it on a social media platform on 11/16/2023. Facility sent Resident # 4 to secondary provider day center on 11/21/2023 without a coat, shoes or wearing a bra. CNA B and LVN A failed to cover residents during wound care or incontinent care or provide privacy on 11/29/2023. This failure placed all residents at risk of psychosocial harm due to a diminished quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for residents reviewed for accommodation of needs. The facility failed to provide a call light or call pad system to 2 resident rooms (19 and 21) observed during investigation process. During an observation made on 11/29/2023 at 11:59 AM. Observed Resident #3's face pad call light on the floor between the bed and nightstand. Resident #3 was unable to reach and get the call light off the floor. During an observation made on 11/29/2023 at 1:40 PM. Observed Resident #2's call light was on the floor on the right side of the head of the bed. During an observation made on 11/29/2023 at 1:42 PM. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible in 2 of 6 resident rooms (room [ROOM NUMBER] and room [ROOM NUMBER]) located on 1 of 2 nurse stations (Station 1) by not storing hazardous material properly. The facility failed to discard scalpel after debridement of wound and left on bedside table in room [ROOM NUMBER] on 11/29/2023. The facility failed to store hazardous material (1 disposable scalpel) and (1 bottle of Dermal Wound Cleaner) in a secure manner. These failures could place residents at risk for avoidable injuries and infections related to skin punctures.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement and maintain an infection prevention and control program designed to provide a safe environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents reviewed for infection control (Resident #1 and Resident #2). 1. LVN A failed to provide adequate infection control practices while cleaning a wound for Resident #1 on 11/29/202, by not washing hands. 2. LVN A failed to provide adequate infection control practices by incorrectly cleaning a wound from outer to inner wound and contaminating the wound. 3. CNA B failed to provide adequate infection control practices by not washing hands and placing a dirty wipe on the same bed as the Resident #2, behind his back during incontinent care. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 2 (Residents #1 and #3) of 6 residents reviewed. The facility failed to implement a baseline care plan that included the minimum healthcare information necessary to properly care for Resident #1 and Resident #3. This failure could place newly admitted residents at risk for insufficient immediate care needs for the resident being met and maintained. Findings Included: Record review of Resident #1's face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: [...]

Inspectors wroteBased on record review, interview, and observation the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timetables to meet residents' highest practicable physical, mental, and psychosocial needs for 1 of 6 residents (Resident #2) reviewed for care plans. The facility failed to develop a comprehensive care plan for Resident #2 within 7 days after the completion of the comprehensive assessment. This failure could place residents at risk of not receiving the care required to meet their physical, mental, and psychosocial needs to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on interview and record review; the facility failed to ensure residents remained free of any significant medication errors for 1 of 1 resident reviewed for medication errors (Resident #2). The facility failed to administer a dose of Resident #2's IV antibiotic scheduled for 8:00 PM on 09/01/2023. There was no adverse consequence to the missed dose. This failure could result in the resident's infection to relapse and increase of the risk of re-hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartment in that, one medication cart was observed to be unlocked and unattended on Station 1 hallway. One medication cart was observed to be unlocked and unattened on 100 Hallway on intial observation rounds. This failure could result in the theft or misuse of medication, potentially could cause accidental poisoning.