Avir at New Braunfels

Inspectors wroteBased on interview and record review the facility failed to notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understood and, the facility failed to ensure a copy was sent of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 of 2 resident (Resident #1) reviewed for transfers and discharges. The facility failed to provide a 30 day discharge notice for Resident #1 and failed to provide a copy to the Ombudsman. This failure could place residents at risk of inappropriate discharges, and not informing the Ombudsman of a resident discharge, to allow for an appeal process.

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 for 1 of 1 facility 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 ensure residents were treated with respect and dignity and to provide care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 1 dining area reviewed for dining. The facility failed to ensure all residents were served meals on non-disposable dishware on 5/12/2026 through 5/15/2026. This failure could result in the loss of dignity of residents and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were served food that is palatable and attractive for 6 of 9 residents (Residents #1-3, and 3 anonymous residents) reviewed for nutrition. The facility failed to serve Residents #1-3 and 3 anonymous residents food that they found appetizing and attractive. These failures place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs for 1 of 6 residents (Resident #3) reviewed for nutrition. The facility failed to ensure Resident #3 was served a lunch tray on 5/12/2026 and 5/14/2026 that contained a double portion of protein dish and extra sandwich, as ordered by the physician. This failure could result in unintentional weight loss, nutritional deficits, and decreased quality of life.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (Resident #1) reviewed for abuse. On [DATE] at 10:25 p.m., CNA A pried Resident # 1's hands off a chair and grabbed the wrists and physically pushed Resident # 1 causing Resident # 1 to fall to the floor and against the wall which required an evaluation at the local ER due to redness to the wrists and back. This failure was identified as past noncompliance IJ as the facility had instituted adequate corrective measure to prevent recurrence of the noncompliance. The noncompliance began on [DATE] and ended on [DATE]. The facility corrected the noncompliance before the survey began. This failure could result in residents suffering injury, a diminished quality of life, and/or death.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, comfortable, and homelike environment, ensuring residents received care and services safely and that the physical layout of the facility maximized resident independence and did not pose a safety risk for 3 of 6 Residents (Resident #1, Resident #2 and Resident #3) reviewed for homelike environment. The facility failed to hire a contractor to complete the renovation of Resident #1's, Resident #2's, Resident #3's showers for a period of about 6 months. Resident #1, Resident #2 and Resident #3 had to use the toilet in another resident's room or in the main shower room away from their room. This deficient practice could place residents at risk contribute to residents experiencing feelings of dissatisfaction and inconvenience.

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 of 3 Residents (Resident #1) reviewed for resident rights. The facility failed to provide an accessible toilet in Resident #1's room and she urinated on another resident's floor. Resident #1 commented she felt ashamed. This deficient practice could place residents at risk for experiencing feelings of shame.

Inspectors wroteBased on interview and record review, the facility failed to ensure agreements pertaining to services furnished by outside resources specified in writing that the facility assumes responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility for 1 of 1 facility reviewed for dental services. The facility did not have a written agreement with the dental facility for dental care. This failure could place residents at risk for not receiving dental services.

Inspectors wroteBased on interview and record review the facility failed to employ sufficient staff with the appropriate competencies and skills set 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 for ten (10) of ten (10) kitchen staff (Cook D, KS C, KS H, KS I, KS J, KS K, KS L, KS M, KS N, KS O) reviewed for qualified dietary staff . 1. The facility failed to ensure all (Cook D, KS C, KS H, KS I, KS J, KS K, KS L, KS M, KS N, KS O) dietary staff maintained their competencies and skills through regular in-service training. 2. The facility failed to ensure KS C met the requirements for food handling by obtaining a current and valid Food Handler's Certificate. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to serve foods that were palatable and prepare food by methods that conserve nutritive value, flavor, and appearance for one (1) of one (1) kitchen observed and one (1) of eight (8) residents (Resident #3) reviewed for food and nutrition services. The facility failed to serve warm food to residents. These failures could place residents at risk of decreased food intake, hunger, unwanted weight loss, and diminished quality of life.

Inspectors wroteBased on observation, interview and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 (Kitchen 1) of 1 kitchen reviewed for food safety requirements. 1. The facility failed to label and date a container of cheesecake, a container of mashed potatoes, and a container of carrots in the walk-in refrigerator. 2. Food service staff failed to ensure temperatures of foods were checked as required for food safety for all three meals on 12/24/2025, 12/25/2025, and 12/28/2025; for breakfast on 12/26/2025 and 12/27/2025, and for breakfast and lunch on 12/29/2025. 3. [NAME] D failed to utilize the food safe appropriate temperature probe wipes when sanitizing the temperature probe between food items. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for one (1) of eight (8) residents (Resident #1) reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 12/29/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observation, interview and record review, the facility failed to post the required signage acknowledging the use of oxygen in resident room per resident care policies and procedures. The polices and procedures for respiratory care and services provided include, but are not limited to, the posting of cautionary and safety signs indicating the use of oxygen for 1 of 1 Resident's for hall. The facility failed to post cautionary and safety signs indicating the use of oxygen on 12/29/2025 for Resident #1's room. This failure could put residents, family members, and all visitors at risk for potential harm due to the flammability of oxygen.

Inspectors wroteBased on observation, interview and record review, the facility failed to store over the counter medications in accordance with currently accepted professional principles for medication storage room in secure Co-ed unit. The facility failed to ensure that the medication storage room held no expired medications per state and federal guidelines. This failure could cause adverse reactions to residents when ingesting expired medications.

Inspectors wroteBased on observation and interview, 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 13 of 15 days (12/17/2025 - 12/29/2025) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information from 12/17/2025 to 12/29/2025. 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 observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, to store all drugs and biologicals under proper temperature controls in 1 of 1 central supply storage room reviewed for medication storage. The facility failed to store their over-the-counter medications (8 bottles of Acetaminophen 325 mg.) in the central supply storage room maintained within 68 to 77 degrees Fahrenheit per medication recommendations. This deficient practice could place residents at risk of the medications not being as effective as they were designed to work.

Inspectors wroteBased on observation, interview and record review the facility failed to provide maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for 1 of 8 Residents (Resident #2) who were reviewed for homelike environment. The facility failed to ensure Resident #2's shower remodeling project was completed and the floor in the resident room was leveled and safe to walk across. This deficient practice could place residents at risk of unsafe living conditions and avoidable accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to incorporate the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care 1 of 2 residents (Resident #1) reviewed for PASARR services. The nursing facility failed to submit a completed (NFSS) application to ensure Resident #1 received a specialized motorized wheelchair based on her rehabilitation assessment. This deficient practice could place residents at risk for not receiving specialized equipment and result in the decline in their physical condition.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents for 1 of 8 Residents (Resident #3) reviewed for sanitary conditions. The facility failed to ensure the damaged linoleum tile was replaced, the walls were painted, the baseboard behind the bed was sanded and painted in Resident #3's room for a period of approximately 2 months. This deficient practice could place residents at risk of living in uncomfortable and unsanitary conditions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure residents received adequate supervision, to the extent possible for 2 of 8 residents (Resident #48 and Resident #64) reviewed for safety. The facility failed to ensure Resident #48, and Resident #64 were provided adequate supervision as the residents walked out of the women's secure unit doors and out into the facility parking lot on 8/23/25, where Resident #64 fell in-between staff vehicles and obtained a laceration to the back of her head requiring 2 sutures. An IJ was identified on 08/28/2025. The IJ Template was provided to the facility on [DATE] at 05:02 PM. While the IJ was removed on 08/29/25, the facility remained out of compliance at a scope of isolated and a severity with no actual harm due to the facility's need to complete repairs and evaluate the effectiveness of the corrective systems. [...]

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 transmission of communicable diseases and infections for 3 of 3 laundry carts. The facility failed to ensure laundry staff handled and delivered linens in a manner to ensure cleanliness and protect from dust and soil to prevent cross-contamination and the spread of infections. This failure could place residents at risk for development of communicable diseases and infections that could diminish a residents' quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to retain and use personal possessions including cigarettes for two (Resident #13 and Resident #37) of four residents reviewed for the right to use personal possessions. The facility failed to return the residents personal cigarettes for Resident #13 and Resident #37 on 08/13/2025. This failure could place residents at risk of having their rights infringed upon and could lead to the residents not being able to use their personal cigarettes when resident were off facility grounds. [...]

Inspectors wroteBased on interview and record review, the facility failed to assess a resident using the quarterly review (every 3 months) instrument specified by the State and approved by CMS for 1 of (Resident #92) of 5 residents reviewed for quarterly MDS assessments. The facility failed to complete a quarterly MDS assessment for Resident #92 every 3 months (04/19/2025 through 08/22/2025). This failure could place residents at risk of not having accurate assessments completed timely which could result in the residents not receiving necessary care or receiving inappropriate care for their conditions.

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 discarded before the expiration date for 2 medications stored in 1 of 2 medication rooms observed for medications. The facility failed to ensure that Med room [ROOM NUMBER] did not have expired OTC medications in the drawer/room. The failures could result in residents receiving ineffective, expired medications which could be harmful. An observation and audit were conducted 08/28/2025 at 10:21 AM of Med room [ROOM NUMBER] which was located in the main lobby revealed that inside a mini fridge were expired insulin and Bisacodyl. The insulin had an expiration date of 08/21/2025. The Bisacodyl had an expiration date of 04/29/2025. [...]

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 control and labeled in accordance with currently accepted professional principles for 2 (medication cart #1 and medication cart #3) of 4 medication carts reviewed for medication storage. The facility failed to ensure that MC #1 did not have loose unknown NARC medications in the drawer. The facility failed to ensure that MC #1 and MC #3 did not have medications that were undated in the drawer. This failure could put residents at risk for missed medications and/or receiving unidentified medications. An observation and audit conducted on 08/27/2025 at 12:50 PM revealed Med Cart #1 which was stationed on the 50 hall, contained loose and unlabeled medications. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 4 of 4 resident hallways (Hallway A, Women's Unit, Hallway C, and Men's Unit) reviewed for environmental concerns. 1. The facility failed on 8/13/25 to ensure the ceiling lights were replaced and the ceiling vent cleaned in the therapy bathroom located at the end of the A- hallway.2. The facility failed on 8/13/25 to ensure the ceiling vents/panels were cleaned/repaired and a shower room in room # 32 cleaned on the Women's Unit.3. The facility failed on 8/13/25 to repair a bedroom light in room [ROOM NUMBER] and clean a shower room in room # 70 on the C-hall.4. The facility failed on 8/13/25 to repair a bathroom floor molding in room # 89 on the Men's Secure Unit. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's care plan reflected his bowel incontinence and included a care plan regarding how to take care of his bowel incontinence. These deficient practices could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder and bowel received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 2 residents (Resident #1) reviewed for incontinence care. When CNA-A was providing incontinent and bladder indwelling catheter care to Resident #1 on 07/10/2025, CNA-A did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region), left groin area, right groin area, and scrotum. These failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for residents 1 of 1 secure unit reviewed for activities, in that: The facility failed to ensure there were organized activities available to residents. The failure placed residents at risk for a diminished quality of life, isolation, and lack of stimulation.

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 5 residents (Resident #1) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when CNA-A provided peri and catheter care for Resident #1. This deficient practice could place residents at-risk for spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the right to be free from abuse for 6 of 11 residents (Residents #4, #5, #7, #8, #10, and #11) reviewed for abuse as evidenced by: 1. Facility failed to address that Resident #3 sexually assaulted Resident #4 on 12/14/24. 2. Facility failed to address that Resident #3 physically assaulted Resident #5 on 12/15/24. 3. Facility failed to address that Resident #7 reported to CNA B that Resident #3 was sexual inappropriate with Resident #7 on 12/13/2024. 4. Facility failed to address that Resident #3 was sexually inappropriate with Resident #10 and reported to Social Worker A on 12/16/2024. 5. Facility failed to address that Resident #11 reported to Social Worker A that Resident #3 was being sexually inappropriate and moved out of Resident #3's room on 12/04/2024. 6. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assured accurate administering of all drugs to meet the needs of residents for 1 of 11 residents (Resident #3) reviewed for pharmaceutical services, in that: 1. MA A administered Resident #9's Gabapentin to Resident #3 when Resident #3 did not have the medication available on 12/14/2024. 2. The facility did not reorder Resident #3's Lyrica, Gabapentin and Clonazepam timely, resulting in Resident #3 missing 3 doses of Lyrica, 5 doses of Gabapentin and 2 doses of Clonazepam. 3. LVN A received an Ativan prn order from NP A on 12/14/2024 for Resident #3 and did not add the medication to Resident #3's physician orders or order the medication from the pharmacy. 4. LVN C documented LVN C administered an Ativan prn to Resident #3 on 12/15/2024 that had not been administered. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' physical, mental, and psychosocial needs that were identified in the comprehensive assessment and to ensure that the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being, including the right to refuse treatment for 4 of 30 residents (Residents #24, #59, #88 and #97) reviewed for care plans. 1. The facility failed to implement a comprehensive person-centered care plan to address Resident #24's diagnosis of depression. 2. [...]

Inspectors wroteBased on interviews 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. The Dietary Manager (DM) did not have the appropriate certification, education, or qualifications 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 observation, interview, 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, in that: 1. The DM wore a facial hair restraint that did not cover all his facial hair. 2. The facility failed to store, label and date food items properly in the walk-in cooler and dry storage room. 3. In the dish room there were multiple trays of plastic cups stored on trays without air-drying nets separating them from the trays. 4. One of the two reach-in freezers in the dining room (Freezer #1) failed to maintain temperatures at a level to keep frozen food solid. 5. DAs G and H were not wearing hair restraints during food preparation in the kitchen. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 2 reach-in freezers (Freezer #1) reviewed for essential equipment. The facility did not ensure Freezer #1 was in safe operating condition. This failure could place the residents at risk of foodborne illness for consuming food not stored at a safe temperature.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. The facility failed to repair a gap surface on a wall in a resident's room, repair a penetration in a resident's bathroom wall, replace light bulbs in a shower stall in a hallway shower room, repair a cracked corner surface of a shower stall in a hallway shower room, clean the dirt/dust particles a bathroom ceiling vent in two residents' rooms, and remove mold from the floor surface of a shower stall in a hallway shower room. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

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, in that: Resident #276's baseline care plan did not include her prescribed diet, food allergies, or code status. This deficient practice could result in newly admitted residents receiving improper care.

Inspectors wroteBased on observations, interviews, 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 4 residents (Resident #385), reviewed for infection control. LVN B failed to sanitize or wash her hands between glove changes during wound care for Resident #385. This failure could place residents at risk of cross contamination, infection, delayed wound healing, and illness.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that the resident environment remained as free of accident hazards as was possible and that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 8 residents (Residents #1 and #2) reviewed for accidents hazards and supervision, in that: 1. On [DATE] at 8:54 a.m., Resident #1 was found outside the facility near a busy two way street near the facility. The facility did not investigate whether Resident #1 had received adequate supervision. Also, the facility did not have a mechanism in place for monitoring the front door to ensure resident supervision/monitoring resulting in Resident #1's elopement. 2. On [DATE] at 6:45 a.m., Resident #2 was found bleeding from the head from an unwitnessed fall in the Women's Secured Unit. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property was provided for 1 of 9 residents (Resident #9) reviewed for misappropriation and exploitation, in that: The facility did not prevent Resident #9's personal belongings from being lost when he discharged to the hospital. This failure could affect residents and their responsible party by preventing them from having access to their personal effects and belongings.

Inspectors wroteBased on interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 7 residents (Resident #1) reviewed for adequate supervision. 1. Resident #1 who required total assistance in eating and received a cup of coffee ,on 08/28/23, from CNA C that he spilled on himself which resulted in significant injury to the right torso region area. 2. CNA C did not check on Resident #1's MDS, care plan, or with the Charge Nurse as to the level of eating assistance Resident #1 required. 3. The facility did not investigate the accident for two days or put in place adequate supervision for other residents (R#6, #7, #8, #9, #10, and #11) with total assistance for eating. An IJ was identified on 12/01/23. The IJ template was provided to the facility on [DATE] at 12:35 PM. [...]

Inspectors wroteBased interview and record review the facility failed to immediately inform the resident's responsible party and physician when there was a significant change in the resident's physical, mental or psychological status for one resident (Resident #1) reviewed for notification of change of condition, in that: The facility failed to notify Resident #1's responsible party and physician when Resident #1 sustained a burn injury after spilling hot coffee on himself. The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 1 of 7 residents (Reident #1), reviewed for care plan revisions, in that: Resident #1's care plan was not revised a total of four times changes were made to the MDS specific to eating assistance. This deficient practice could place residents at risk for lack of coordination of services and confusion as to eating assistance.

Inspectors wroteBased on interview and record review the facility failed to ensure that licensed nurses had the appropriate competencies and skill sets to provide nursing and related services to assure resident safety for 2 of 29 licensed staff (LVN A and LVN B) reviewed for competent staff, in that: 1. The facility failed to ensure LVN A completed an incident report and notified Resident #1's RP and physician after he sustained a burn incident. 2. The facility failed to ensure LVN B documented care provided to Resident #1 in his EMR. The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which were complete and accurate for one resident (Resident #1) reviewed for accuracy of records, in that: The facility did not document in Resident #1's electronic medical record (EMR) an incident report or care that was provided after the resident sustained a burn injury. The non-compliance was identified as past non-compliance. The non-compliance began on 08/28/2023 and ended on 09/01/2023. The facility had corrected the non-compliance before the survey began. These failures could place residents at risk of not having accurate medical records and could create confusion in services provided or needed to be provided.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to follow menus for 1 of 1 resident meals (lunch meal on 04/11/2023) reviewed for menus in that: 1. Residents on a regular diet were served lunch items on 04/11/2023 that did not reflect what was on the menu. 2. Residents on modified diets were served lunch items on 04/11/2023 that did not reflect what was on the menu. These failures could place residents who consume food prepared by the facility kitchen at risk of not having their nutritional needs met and/or weight loss.

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 for 1 of 1 kitchen, in that: 1. There was a zip-locked bag in the reach in cooler with diced ham that was past its use-by date. 2. There was an open bag of flour in the dry storage room that was not stored in a closed or tightly covered container. 3. The tabletop can opener blade, bar, and base were covered in sticky black and brown grime. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

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 3 of 6 residents (Residents #44, #94 and, #114) reviewed for infection control, in that: 1. LVN X did not wash or sanitize her hands or change her gloves after touching Resident #44's environment and before starting wound care for Resident #44. 2. CNA Y and CNA D did not wash or sanitize their hands or change their gloves after touching Resident #94's environment and before starting incontinent care for Resident #94. 3. LVN A did not wash or sanitize her hands between change of gloves during colostomy care for Resident #114. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure Quality Assurance Performance Improvement (QAPI) Training that outlines and informs staff of the elements and goals of the facility's QAPI program for 13 of 23 staff (CNAs E, F, G, H, I, J, K, L, and LVNs N, Q, and ST, PT, and OT, reviewed for training, in that: The facility failed to ensure that 13 of 23 staff (CNAs E, F, G, H, I, J, K and LVN's N, Q, and ST, PT, OT staff had completed their mandatory QAPI annual training. This failure could place residents at risk for care by CNA, LVN, and therapy staff who have been insufficiently trained while working in the facilit

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 resident (Residents #44 and, #114) reviewed for privacy, in that: 1. LVN X did not completely close Resident #44's privacy curtain while providing wound care for the resident. 2. LVN A did not completely close Resident #114's privacy curtain while providing colostomy care for the resident. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed conduct initially and periodically a comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity within 14 days calendar days after admission, excluding readmissions in which there is no significant change in the resident's physical or mental condition for 1 of 7 resident (Resident #423) reviewed for Comprehensive Assessments and timing. The facility failed to ensure an MDS Assessment for Resident #423 was completed within 14 days after admission. This failure could place residents at risk for 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 develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident's rights, 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 for 1 of 47 residents (Resident #2) whose care plan was reviewed, in that: The facility failed to ensure Resident #2's care plan included insulin This deficient practice could place residents at risk of receiving the incorrect care and cause health complications with subsequent illness.