Avir at Mineola

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents were free from physical abuse for 1 of 10 residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 was free from physical abuse when CNA B was in Resident #1's room on the secured unit handled Resident #1 in a rough manner during patient care, pinning Resident #1 down multiple times. CNA B placed his forearm and hands on Resident #1's chest/ neck area, and CNA B placed both hands around Resident #1's neck in a choking manner while pushing Resident #1 into his bed. Resident #1 suffered bruising to his chest, right forearm, and left forearm from CNA B physical force and abuse towards him on 5/5/26. The noncompliance was identified as past noncompliance (PNC). The IJ began on 5/5/26 and ended on 5/6/26. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they did not employ an individual who was found guilty of abuse, neglect, exploitation, misappropriation of property, or mistreatment by a court of law for 1 of 1 (Cook A) employees reviewed for abuse and neglect. The facility did not disqualify [NAME] A from working when her criminal history record indicated she had a criminal conviction barring employment in a nursing facility. [NAME] A worked in the facility from 11/04/24 through 04/24/26. This failure could place residents at risk for possible abuse, neglect, exploitation or mistreatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 (Resident #1) residents reviewed for notification of change. The facility failed to ensure Resident #1's physician was notified when she had a fall which resulted in an abrasion to her face on 03/18/2026. This failure could place residents at risk for experiencing unnecessary pain, not receiving necessary treatments and medications, and a decreased quality of life.

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 10/06/25, 10/10/25, 10/14/25, 10/16/25, 10/17/25, 10/17/25, 10/18/25, 10/19/25, 10/20/25, 10/24/25, 10/29/25, 10/30/25, 10/31/25, 11/04/25, 11/07/25, 11/10/25, 11/14/25, 11/19/25, 11/21/25, 11/26/25, 11/27/25, 11/28/25, 12/01/25, 12/02/25, 12/03/25, 12/04/25, and 12/05/25 (27 days from 10/06/25 through 12/09/25). This deficient practice had the potential to place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary clean, comfortable, and homelike environment for 3 of 21 residents reviewed for environment. (Resident #28, Resident #63 and Resident #66) 1. The facility failed on 12/08/2025 to ensure that Resident #28's bathroom was cleaned of water, an unidentified black track marks on the tile when the sink was leaking. 2. The facility failed to replace missing pieces from Resident #63 and Resident #66 window blinds. These failures could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 1 of 1 facility reviewed for nurse staffing posting. The facility failed to post the required current daily staffing information on 12/8/25 and 12/9/25. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

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 3 of 14 residents (Resident #17, Resident #38 and Resident #60) reviewed for infection control practices. 1. The facility failed on12/09/25 to ensure that LVN A sanitized her hands while passing medications to Resident #38 and Resident #60. 2. The facility failed on 12/08/2025 to ensure that Resident #17's room was cleaned of feces, urine, and a unidentified black marks on the tile floor and bathroom. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 6 residents (Resident #9) reviewed for PASRR. The facility failed to refer Resident #9 for PASRR level II assessment, to the state-designated authority, upon receipt of a psychosis (symptoms that happen when a person is disconnected from reality) diagnosis. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 1 resident (Resident #6) reviewed for respiratory care and services. The facility failed to clean the filter on an oxygen concentrator machine that was in use for Resident #6 on 12/08/25 and 12/09/25. This failure could place residents at risk for developing respiratory complications.

Inspectors wroteBased on interview and record review , the facility failed to provide pharmaceutical services, including the accurate acquiring, administering, and receipt of all drugs and biologicals, to meet the needs of 1 of 18 residents (Resident #31) reviewed for pharmacy services. The facility failed to ensure that 1 tablet of Resident #31's prescribed Hydrocodone (opiate pain medication) was properly accounted for and not missing on 12/10/25. This failure could place residents at risk for decreased quality of life, unrelieved pain, and dignity.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs were stored in a locked compartment and only accessible by authorized personnel for 1 of 13 (Resident #2) residents reviewed for medication storage and 1 of 4 medication carts (#1, #2, #3, #4). The facility failed to securely store medications, albuterol inhaler, for Resident #2. The facility failed to securely store medications, nystatin topical powder, in the locked drawers of the medication cart. This failure could place residents at risk for adverse reactions.

Inspectors wroteBased on observation and interview the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 1 secured unit living rooms observed. The facility failed to ensure CNA D and LVN B did not have a blanket covering the overhead light in the secured unit living room on 9/18/25. This failure places residents at risk for a fire hazard and decreased quality of life. Findings Include:During an observation on 9/18/25 at 4:35 a.m. LVN B and CNA D were in the secured unit living room with a blanket covering the overhead light. LVN B was observed removing the blanket when the surveyor and a CNA walked into the secured unit living room. During an interview on 9/18/25 at 4:41 a.m. LVN B said covering the overhead light in the living room of the secured unit was not safe. [...]

Inspectors wroteBased on observation, interview, and record review, in accordance with State and Federal laws, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys on 3 of 7 (Medication Cart #1, Medication Cart #2, and Medication Cart #3) medication carts reviewed for labeling and storage of medication. The facility did not ensure the Medication Cart #1 (medication cart for the secured unit), Medication Cart #2 (nurse's medication cart for the west side of the building) and Medication Cart #3 ((nurse's medication cart for the east side of the building) were secured and unable to be accessed by unauthorized personnel on 9/18/25. This failure could place residents at risk for not receiving drugs and biologicals as needed or a drug diversion.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from any physical or chemical restraints imposed for purposes of discipline or convenience and not required to treat the resident's medical symptoms 1 of 13 (Resident #1) residents reviewed for restraints. The facility failed to ensure Resident #1 was administered her Xanax (medication used to treat anxiety) every 8 hours as needed per the physician's orders instead of Resident #1 having it administered in less than 8 hours on several dates in July 2025 by LVN A and LVN B to keep Resident #1 quiet. This failure could place residents who receive psychotropic medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure registry verification was received that the individual had met competency evaluation requirements before they were allowed to work as a nurse aide for 1 of 4 (CNA E) employees reviewed for registry verification. The facility failed to ensure CNA E had a current nurse aide certification while employed at the facility and actively providing care for residents from [DATE] through [DATE]. CNA E certificate expired on [DATE]. This failure placed residents at risk for decreased quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that was, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications) 1 of 13 (Resident #2) residents reviewed for notification of change. The facility did not notify the physician of Resident #2's weeping edema (a condition where fluid leaks from the skin), redness, and blister to her right leg. LVN B or D had not notified the physician or NP to obtain an order for an ace wrap or notify them of the swelling and weeping to Resident #2's right leg on 08/29/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 13 (Resident #2) residents reviewed for quality of care. The facility did not notify the physician of Resident #2's weeping edema (a condition where fluid leaks from the skin), redness, and blister to her right leg. The facility did not ensure physician orders were obtained for treatment of Resident #'2's swollen and weeping leg or application of dressings prior to applying dressings to Resident #2's leg. These failures could place residents at risk for not receiving care and services to meet resident needs and decreased quality of life.

Inspectors wroteBased interviews and record review, the facility failed to ensure each resident was free from misappropriation of resident property for 2 of 3 residents (Resident #2 and Resident #3), reviewed for drug diversion. The facility failed to prevent the misappropriation of Resident #2 and Resident #3's hydrocodone-acetaminophen 5-325 mg (formerly known under the brand name Norco, this combination medication containing 5 mg of hydrocodone [an opioid analgesic] and 325 mg of acetaminophen [also known as Tylenol] is used to treat pain). This failure could place residents at risk for not receiving their prescribed medications, unrelieved pain, and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical record maintained for each resident were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for resident records. The facility failed to ensure accurate documentation was documented for Resident #1's wound care on 3/21/25 when the DON (who did not perform the wound care) edited LVN B's (the nurse that performed the wound care) progress note for Resident #1 five days after the wound care (3/26/25). This failure could place residents at risk for delayed interventions, appropriate interventions, health complications and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 2 shower rooms (B hall) reviewed for homelike environment. The facility failed to ensure the shower room on B hall did not have black grime buildup on the walls and missing tiles on the floor. This failure could place the residents at risk for a decreased quality of life, an uncomfortable, unhomelike environment due to unsanitary conditions.

Inspectors wrote8. Record review of a face sheet dated 04/09/2025 indicated Resident #6 was a [AGE] year-old male initially admitted to the facility on [DATE] and re-admitted on [DATE] with diagnoses which included diffuse traumatic brain injury with loss of consciousness (injury to the brain which results in loss of consciousness), bipolar disorder (a disorder associated with episodes of mood swings ranging from depression lows to manic highs), and schizophrenia (mental disorder characterized by delusions, hallucinations, disorganized thoughts, speech and behavior). Record review of the Comprehensive MDS assessment dated [DATE] indicated Resident #6 was understood and understood others. The MDS assessment indicated Resident #6 had a BIMS of 15, which indicated his cognition was intact. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests for 4 of 18 (Resident #3 Resident #4, Resident #9 and Resident #14) residents reviewed for pest control. The facility did not maintain an effective pest control program to ensure the facility was free of roaches and water bugs. This failure could place residents at risk for an unsanitary environment and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure the residents had the right to be informed, in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or options he or she preferred for 1 of 13 residents (Resident #13) reviewed for resident rights. The facility failed to get written consent from Resident #13 on the HHSC form 3713 for having Seroquel (antipsychotic medication) prescribed. This failure could place residents at risk for receiving unnecessary antipsychotic medications without informed consent.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 2 of 18 residents (Resident #3 and Resident #13) reviewed for grievances. 1. The facility did not ensure a grievance was filed for Resident #3's underwear that was part of the facility fire. 2. The facility did not ensure a grievance was filed for Resident #13's missing pants. These failures could place residents at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain grooming and personal hygiene for 1 of 10 residents reviewed for ADLs. (Resident #35) The facility failed to ensure Resident #12 received his shower as scheduled. This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem.

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents had the right to a clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safety, clean bed and bath linens for 1 of 1 facility reviewed for resident rights. The facility failed to ensure clean towels and wash rags were available for use on 09/11/24. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure prompt efforts were made to resolve grievances for 4 of 4 residents (Resident #'s 10, 46, 73, and 182 ) reviewed for grievances. The facility failed to appropriately resolve Resident #46, Resident #182, Resident #73 and Resident #10's grievances when issues with missing clothing from continued from May 2024 to September 2024. This failure could place residents at risk for grievances not being addressed or resolved promptly.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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: 1) The facility failed to label and date all food items. 2) Dietary staff failed to dispose of expired foods items. 3) Dietary Staff failed to effectively reseal, label and date frozen food items. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 3 of 4 residents (Resident #27, Resident #35, and Resident # 15) reviewed for hospice services. The facility failed to maintain Resident #27's, Resident #35's, and Resident #15's hospice binder containing information related to hospice services provided for the resident such as the most recent plan of care, hospice election form, physician recertification, and hospice medication profile. [...]

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 3 of 4 (Resident #35, Resident #60 and Resident #77) and 1 of 1 laundry room reviewed for infection control practices. 1. The facility failed to ensure the ADON and CNA D wore proper PPE when providing incontinent care and wound care to Resident #35 who was on enhanced barrier precautions (EBP) refers to an infection control intervention designed to reduce transmission of multidrug-resistant organisms that employ targeted gown and gloves use during high contact resident care activities. 2. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the residents or responsible party had the right to be informed of and participate in his or her treatment which included, the right to be informed in advance, by the physician or other practitioner or other professional, of the risks and benefits of proposed care, treatment, and treatment alternatives or treatment options to choose the alternative or option he or she preferred for 1 of 4 residents (Resident #74) reviewed for psychoactive medications. The facility failed to ensure LVN B obtained informed consent based on the information of the benefits and risks for Resident #74 before administering Klonopin (Clonazepam), a medication used to treat anxiety on 08/28/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 of 21 residents (Residents # 46), reviewed for care plans. The facility failed to revise Resident #46's care plan after he fell on [DATE], 07/12/2024, and 08/25/2024. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 1 of 21 residents (Resident #59) reviewed for ADL (activities of daily living) care. The facility failed to provide facial hair removal/shaving for dependent female Resident #59 on 09/09/2024. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 21 residents reviewed for laboratory services (Residents #46). The facility failed to obtain ordered Depakote level (level obtained to ensure medication is in therapeutic range) for Resident #46. This failure could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 3 bathrooms reviewed for physical environment. The facility failed to ensure Resident #1's bathroom was clean and free of odors. This failure could place residents at risk for a decreased quality of life and an unsanitary environment.

Inspectors wroteBased on observations, interviews, and record review the facility failed to maintain an effective pest control program so that facility is free of pests and rodents for the 1 of 3 bathroom's reviewed for pests. The facility did not maintain an effective pest control program to ensure the facility was free of roaches in Resident #2's bathroom on C Hall. These findings could place residents at risk for an unsanitary environment and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 1 of 6 (Resident #55) reviewed for quality of care. The facility failed to obtain treatment for Resident #55's urinary tract infection thus leading to Resident #55's hospitalization. An IJ was identified on 8/09/2023. The IJ template was provided to the facility on 8/09/2023 at 1:24 p.m. While the IJ was removed on 8/09/2023, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on notification of changes and evaluate the effectiveness of the corrective systems. This failure could place residents at an increased risk for exacerbation of infections, septicemia, and even death.

Inspectors wroteBased on interview and record review the facility failed to consult with the resident's physician when there was a significant change in the resident's physical and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 6 (Resident#55) residents reviewed for notification of change of condition. The facility failed to consult with the physician when Resident #55 who had a low blood pressure reading, malaise (general feelings of discomfort, illness), fever, and weakness. The facility failed to consult Resident #55's physician of the urinalysis results and obtain a treatment. An IJ was identified on 8/09/2023. The IJ template was provided to the facility on 8/09/2023 at 1:24 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and establish policies and procedures to report and investigate such allegations, for 3 of 11 residents (Resident's #37, #49 and #69) reviewed for abuse. 1. The facility did not implement policy on reporting abuse for bruise of unknown origin for Resident #37 to the abuse coordinator (Administrator). 2. The facility did not implement policy on reporting abuse timely for Resident #49 and Resident #69. These failures could place the residents at increased risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 3 of 3 residents (Resident #37, Resident #49 and Resident #69) reviewed for abuse and neglect. 1. The facility failed to report Resident #37's left cheek bruise, an injury of unknown origin, timely to HHS. 2. The facility failed to report Resident #49's bruised eye and nose, an injury of unknown origin, timely to HHS. 3. The facility failed to report Resident #69 and Resident #37 resident -to-resident altercation timely to HHS. These failures could place the residents at increased risk for further potential abuse due to unreported and uninvestigated allegations of abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 3 of 4 licensed staff (LVN D, LVN F, ADON/LVN O). The facility failed to ensure that LVN D, LVN F, and ADON/LVN O, who were charge nurses for a resident with a central venous line catheter, were competent in providing medication administration via the central venous line catheter (a catheter placed in a large vein up near the heart). This failure had the potential to affect residents by placing them at an increased and unnecessary risk of exposure to staff who lack the appropriate skills competencies to provide care that is safe and capable of minimizing accidents from procedural errors, infections, and errors in medication administration.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private space for residents' monthly council meetings for 9 of 9 confidential residents reviewed for resident council. The facility did not provide a private space for resident council meeting. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 1 (Resident #42) residents' bathrooms reviewed for environment. 1. The facility failed to ensure Resident #42 did not a have sticky floor near the toilet in the bathroom. This failure could place residents at risk of an unsafe or uncomfortable environment and a decrease in quality of life and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations of abuse and neglect were thoroughly investigated for 1 of 3 residents (Resident #37) reviewed for abuse and neglect. The facility did not thoroughly investigate when Resident #37 had a bruise of unknown origin on his left cheek. This failure could place residents at risk for abuse and neglect.

Inspectors wroteBased on interview, and record review the facility failed to implement a person-centered care plan to meet resident's medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 1 of 25 residents (Resident # 55) reviewed for care plans. The facility failed to care plan Resident #55's need for contact isolation related to a contagious urinary tract infection with ESBL from July 5, 2023 - July 11, 2023. This failure could place residents at risk for injuries, inaccurate care plans and decreased quality of care.

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 services to maintain grooming and personal hygiene for 1 of 3 (Resident #69) residents reviewed for ADLs. The facility failed to ensure Resident #69's fingernails were clean and free from a brown colored material. This failure cold place residents at risk for not receiving services/care and decreased quality of life.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure residents received proper treatment and assistive devices to maintain or enhance vision abilities for 1 of 1 resident reviewed for vision services. (Resident #55). The facility failed to schedule Resident #55 for a consult for cataract surgery. This failure could affect resident in need of referrals for vision evaluations and place them at risk of not receiving necessary treatment and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 5 of 28 residents (Resident #'s 11, 33, 42, 54 and 63). The facility failed to ensure a safe environment to prevent accidents and hazards when Resident #33 hit Resident #11, put her hand in Resident #63's shorts, and served other residents drinks, including Resident #62 who was on thickened liquids. The facility failed to ensure a safe environment to prevent accidents and hazards for Residents #63 and #54, and #42, with the razors in the bathroom not stored securely. This failure could place residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that respiratory care was provided consistently with professional standards of practice for 1 of 4 residents reviewed for respiratory care. (Resident #22) The facility failed to ensure Resident #22's CPAP (continuous positive airway pressure) had the correct setting to ensure proper respiratory exchange. This failure could place residents at risk for shortness of breath and increased sleep apnea.

Inspectors wroteBased on interview, observation, 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 25 residents (Resident #122) and 1 of 3 medication carts (C Hall) reviewed for pharmacy services. The facility did not remove expired medications from C Hall nurse cart. The facility failed to administer Resident #122's prescribed sodium chloride tablets. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure psychotropic medications were not given unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents reviewed for unnecessary medications. (Resident #23) The facility failed to have an appropriate diagnosis or adequate indication for the use of Resident #23's Seroquel (antipsychotic medication used to treat certain mental/mood disorders such as schizophrenia, and bipolar disorder). This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 3 medication carts (medication and nurse carts) reviewed for storage of medications. The facility failed to ensure Hall C medication cart and Hall A, B, and D nurses' cart was secured and unable to be accessed by unauthorized personnel. This failure could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 2 of 28 residents reviewed for laboratory services (Residents #'s 41 and 10). The facility failed to obtain ordered CBC (Complete Blood Count), CMP (Complete Metabolic Panel), B12/Folate, Stool Culture, Vitamin D, Lipids, TSH (Thyroid Stimulating Hormone, and FER (Ferritin) levels for Resident #41. The facility failed to obtain ordered A1C for Resident #10. These failures could place residents at risk of not receiving timely diagnoses, treatment, and services to meet their needs.