Avir at Patriot

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and PASRR evaluation report into the resident's assessment, care planning, and transitions of care for 1 of 3 (Resident #8) residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days. The LTC online portal was subsequently reopened on 06/27/2026 to allow the facility to resubmit documentation reflecting the 04/16/2026 IDT meeting; submission remained incomplete and was not closed. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 13 residents (Resident #1) reviewed for quality of care.-The facility failed to immediately notify the physician and/or nurse practitioner on [DATE] at 6:06 p.m. when the laboratory called to report WBC critical results for Resident #1. -The facility failed to immediately notify the physician on [DATE] of Resident #1's worsening condition, continued abdominal pain, elevated blood glucose at 563 and became unresponsive. Resident #1 was transferred to the hospital emergency room and expired on [DATE].-The facility failed to monitor blood glucose on Resident #1 when she as admitted to the facility on [DATE] and was taking multiple oral hypoglycemic medications to treat Diabetes Mellitus. [...]

Inspectors wroteBased on interview and record review, the facility failed to consult with the resident's physician and representative when there was a significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of (Resident #1) 13 residents reviewed for changes in condition. The facility failed to notify Resident #1's physician Resident #1 was complaining of abdominal pain on 2/20/26 and 2/22/26. This failure could place residents at risk of not receiving adequate and timely intervention and a decline in condition.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 2 of 13 residents (Residents #1 and #2) reviewed for clinical records with transfer assistance.-The facility failed to ensure LVN C documented in Resident #1's clinical record on 2/18/26 that the attending physician gave new orders for labs, Abd US and KUB when resident had a change in condition.-The facility failed to ensure RN A Weekend supervisor documented in Resident # 1's clinical record on 2/18/26 when Abd US and KUB results were sent to the attending physician. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure efforts were made to resolve resident grievances, for 1 (Resident #2) of 13 resident reviewed for grievance resolution. The facility failed to follow their facility policy and procedure on Grievance/Complaints when Resident #2's family member voiced a concern on 01/30/26 to LVN M regarding the way that the staff combed the resident hair and concerns regarding food. This failure could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse for 1 (Residents #3) of 13 residents reviewed for abuse. The failed to ensure allegations of abuse were immediately reported by the facility staff to the Administrator when Receptionist X witnessed when Resident #4 calling Resident #3 a cow. This failure could place residents at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure another physician supervises the medical care of residents when their attending physician is unavailable for 1 (Resident #1) of 13 residents reviewed for physician services. The facility failed to ensure another physician was available to supervise the medical care for Resident #1's when her condition continued to worsen, continued abdominal pain, elevated blood glucose at 563 and became unresponsive. Resident #1 was transferred to the hospital emergency room and expired on [DATE]. This failure could place residents at risk of delayed treatment/intervention, decline in health and/or death.

Inspectors wroteBased on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident, for 1 of 13 Residents (Resident #1) reviewed for medication administration.:The facility failed to ensure facility's emergency insulin kit contained Lantus to use in an emergency when Resident #1's blood glucose reading was at 517 on [DATE]. The physician gave a STAT order for Lantus and was not available in the facility's emergency insulin kit. The nurse borrowed a Lantus insulin vial that belonged to another resident. This failure could place residents at risk of not receiving prescribed medications that could result in delayed medical treatment and decline in medical condition.

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, mental, or psychosocial status for 1 of 3 residents (Resident #1) reviewed for physician notification of changes. The facility failed to immediately consult with the physician and/or Nurse Practitioner when resident's family member requested to transfer Resident #1 to the emergency room for evaluation of ecchymosis and blood blister in the middle of the chest. This failure could place residents at risk of delayed medical treatment. Findings Included:Review of the admission Record dated 10/24/25 revealed Resident #1 was originally admitted to the nursing facility on 03/31/25 and re-admitted on [DATE]. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure the resident had the right to prompt efforts by the facility to resolve resident grievances, for one (Resident #2) of three residents reviewed for grievance resolution. The facility failed to ensure prompt efforts to resolve grievances voiced by Resident #2's family who filed a grievance on 08/22/25 and 10/17/25. This failure could place residents at risk of feeling that their voices were not being heard or taken seriously and could cause feelings of worthlessness.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented, in accordance with accepted professional standards and practices, for 1 of 3 residents (Resident #1) reviewed for clinical records. The facility failed to ensure LVN I accurately documented in Resident #1's Event Report on 10/20/25 when the resident returned from the dialysis center with ecchymosis and a blood blister in the middle of the chest. The facility failed to ensure the DON documented skin assessment for Resident #1 according to facility policy on documentation. The facility failed to ensure LVN I wrote a physician's telephone order on 10/22/25 to send Resident #1 to the emergency room for evaluation of ecchymosis and a blood blister in the middle of the chest. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were provided services with reasonable accommodation of needs and preferences for 3 of 12 residents (Resident #45, #46 and #47) reviewed for call lights. The facility failed to ensure resident call lights were within reach for 3 Resident #45, #46 and #47). This failure placed residents at risk of having their needs unmet when they are unable to contact staff.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide ADL care for 2 of 16 residents (Resident # 99 and #156) reviewed for ADLs.-The facility failed on 08/26/2025 to ensure Resident #99 and #156's fingernails were trimmed, clean and free from debris.-This failure could place residents at risk of not having their personal hygiene needs met and cause low self-esteem.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who are incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 (Resident #39) of 6 residents reviewed for incontinent care. The facility failed to ensure adequate bladder incontinence absorbent products were provided to address urine leakage and dignity for Resident #39. This deficient practice could place residents at-risk for infection; skin break down and decrease in self-worth due to improper care practices.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 of the facility's laundry department reviewed for patient care equipment in safe operating condition. -The facility failed to maintain 1 of 3 washers in operating condition. The failure could place residents at risk for harm by the facility's inability to provide clean sanitary linens and could place residents at risk for poor hygiene and health.

Inspectors wroteBased on interview and record review, the facility failed to ensure the prompt resolution of all grievances to include providing a written summary of investigation to resident or resident representative filing the grievance for 1 (Resident #114) of 6 residents reviewed for resident rights. -The facility failed to provide a written summary of the investigation to resident or resident representative who filed the grievance as per facility policy for Resident #114. - The facility Administrator failed to follow up on grievances related to misappropriation of personal property for Resident # 114. This failure could place residents at risk of not receiving resolutions to their grievances.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 1 (Resident #131) of 6 residents reviewed for oxygen use. The facility failed to maintain Resident #131's oxygen concentrator filter free from lint and dust. This deficient practice could place residents who receive continuous oxygen at risk for not having their air properly filtered. Findings Include:Record Review of Resident #131's face sheet dated 08/27/25 revealed a [AGE] year-old female with admission date 08/12/25. Record review of Resident #131's Nursing Home PPS (Prospective Payment System) MDS dated [DATE] revealed a BIMS score of 14, which indicated the resident was cognitively intact. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 4 nurse medication carts (400) reviewed for medication storage. The nurse medication cart used for hall 400 was inspected on [DATE] and had an insulin vial that had an open date of [DATE] which meant the insulin had already expired. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.

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 to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #44) reviewed for incontinent care in that; CNA A failed to change her gloves after they became contaminated during incontinent care while assisting Resident #44. The failure could place resident's risk for cross contamination and the spread of infection.

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 two of five residents (Residents #2 and #3) reviewed for Enhanced Barrier Precautions. The facility failed to implement their policy on Enhanced Barrier Precautions for residents with wounds and/or indwelling medical devices. These failures could place residents at risk for healthcare associated cross-contamination and at risk of the transmission of multi-drug-resistant organism (MDROs).

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents who entered the facility received care and treatment consistent with professional standards of practice to prevent pressure ulcers and a resident with pressure ulcers receives necessary treatment and service to promote healing and/or prevent further development of skin breakdown or pressure ulcers, for one (Resident #2) of four residents reviewed for prevention and maintenance of pressure ulcers. The facility failed to ensure Resident #2's dressing was replaced when it became dislodged, allowing the sacral wound to be exposed to potential contamination with urine and fecal matter. This failure could place residents at risk of worsening of existing pressure ulcers and risk of infection.

Inspectors wroteBased on interview, and record review, the facility failed to maintain clinical records on each resident that were complete and accurately documented in accordance with accepted professional standards and practices for 1 (Resident #1) of 6 residents reviewed for accuracy and completeness. The facility failed to ensure that LVN A completed a weekly skin assessment for Resident #1 on 7/22/25 in accordance with facility policy. This failure placed residents at risk for unmet care needs, as services may be documented as provided when they were not, potentially leading to delays in treatment or unidentified changes in condition.

Inspectors wroteBased on interviews and record review the facility failed to coordinate assessments in which a PE was not conducted after the pre-admission screening indicated a yes for intellectual disability and resident review (PASARR) program under Medicaid for 1 (Resident #1) of 3 residents reviewed for PASRR. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting on 05/28/24. This failure could place residents who were PASRR positive at risk of not getting the PASARR services for a better quality of life and could lead to a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 2 (Residents #2, and #3) of 3 residents reviewed for accidents and supervision. The facility failed to provide supervision to prevent accidents for Residents #2 and #3 who exited the facility thru the front door on 2/26/25. The noncompliance was identified as PNC . The IJ began on 2/26/25 and ended 2/27/25. The facility had corrected the noncompliance before the survey began. These failures placed residents at risk of injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment, which included injuries of unknown source and misappropriation of resident property, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials, which included the state survey agency, in accordance with State law through established procedures for 2 of 3 residents (Residents #2, and #3) reviewed for abuse and neglect. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nurse aides were able to demonstrate competency in skills and techniques to care for residents' needs for 1 (Resident #11) of 3 residents reviewed for accidents and supervision. CNA B failed to place brakes on the mechanical lift when lifting Resident #11 from her bed and CNA J failed to place brakes on the wheelchair when the resident was lowered down. These failures placed residents at risk of injuries. The finidings include: Record review of Resident #11's face sheet dated 3/7/25 revealed an [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses of dementia, muscle weakness, and cognitive communication deficit. Record review of Resident #11's quarterly MDS assessment dated [DATE] revealed her cognition was severely impaired and she was dependent on staff for transfers . [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Residents #5) of 5 residents reviewed for call light button placement and 2 (Hall 300 and Hall 400) of 4 hallways reviewed for call light response. The facility failed to ensure that Residents #5's call light was within reach on 12/10/24 and on 12/11/24, while he was in bed. It was observed on 12/11/24, in Hall 300, room [ROOM NUMBER]'s call light was on for 26 minutes while facility staff walked up and down the hallway without entering the resident room. It was observed on 12/11/24, in Hall 300, Room call light was on for 21 minutes while facility staff walked up and down the hallway without entering the resident room. [...]

Inspectors wroteBased on the observation, interview, and record review, the facility failed to ensure residents had the right to be treated with respect and dignity, including the right to be free from any physical restraints imposed for purpose of discipline or convenicence, and not reuqired to treat the residnet's medical symptoms for 2 (Resident #4 and Residnet #5) of 5 residents reviewed for physical restraints. The facility failed to ensure Resident #4 and Resident #5 were not restrained in bed by use of a fall mat being propped up next to the bed being held in place by faciliy furniture. This failure could place residents at risk of unnecessary restriction of their freedom of movement, decrease quality of life, injury, suffocation, and falling.

Inspectors wroteBased on the observation, interview, and record review, the facility failed to ensure that the residents environment remains free of accidents hazards as possible and each resident receives adequate supervision to prevent accidents for 2 (Resident #4 and Resident #5) of 2 residents reviewed for accidents and supervision. The facility failed to put appropriate fall precautions in place when staff blocked residnets in bed with furniture and fall mats for Resident #4 and Resident #5. Resident #4 was in bed lying on her rights side with her legs curled up against the blue fall mat. Resident #4 had her right arm up and her right hand over her eyes with her mouth open. Right hand was touching the blue fall mat. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to thoroughly investigate allegations of abuse, neglect, exploitation, or mistreatment for 1 of 10 (Resident #1) reviewed for abuse. The facility failed to implement their abuse policy when they failed to immediately suspend CNA A after an allegation of mistreatment was reported. This failure could place residents at risk of potential continued mistreatment and abuse.

Inspectors wroteBased on interviews and record review the facility failed to ensure that the assessment accurately reflected the resident's status 2 (Resident #5, and Resident #6) of 5 resident reviewed for accuracy of MDS assessments. Resident #5's quarterly and annual MDS did not accurately reflect the residents use for bed rails (enablers). Resident #6's quarterly MDS did not accurately reflect the residents use for bed rails (enablers). This deficient practice could affect residents at the facility who had been assessed for risk of bed rails (enablers) could contribute to inadequate care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to assess the resident for risk of entrapment from an enabler (bed rail) prior to installation or review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation for 2 ( Resident #5, and Resident #6) of 5 residents reviewed for enablers (bed rails). Resident #5 did not have a signed consent form for use of bed rails, nor on-going Enabler Assessments being done to ensure the Enablers (bed rails) were still appropriate for the use of Resident #4's needs. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and described the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #9) of 7 residents reviewed for care plans -The facility failed to follow the comprehensive person-centered care plan for Resident #9's fall risk, by failing to have a fall mat in place next to bed while resident was lying down in bed. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services as indicated in their comprehensive person-centered plans developed to address their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #10) of 3 residents observed for oxygen management. -Resident #10 was on oxygen and did not have oxygen signs posted outside his bedroom. This failure could place residents on oxygen therapy at risk of receiving incorrect or inadequate oxygen support and decline in health; and place them at risk of an unsafe environment which could lead to accidents and injuries.

Inspectors wroteBased on interview and record review the facility failed to ensure medical records, in accordance with accepted professional standards and practices, were maintained on each resident that were accurately documented for 2 (Resident #1, and #2) of 8 residents reviewed for medical records. -The facility failed to ensure the right diet texture was documented in the orders of Resident #1. -The facility failed to ensure the right diet texture was documented in the care plan of Resident #1. -The facility failed to ensure accurate documentation was reflected in the Medication Administration Record of Resident #2. These failures could lead to errors in treatment and services provided based on incorrect information.

Inspectors wroteBased on interviews and record review the facility failed to ensure that residents who have not use psychotropic drugs were not given these drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 2 (Resident #274, Resident #111) of 8 residents reviewed for unnecessary medications. The facility failed to ensure Resident #111 had an appropriate diagnosis for the use of Seroquel (an antipsychotic used to treat schizophrenia and bipolar disorder). The facility failed to ensure Resident #274 had an end date for Zyprexa that was ordered PRN (as needed). These failures could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition of functional or psychosocial status from receiving unnecessary antipsychotic medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for sanitation and food storage. The facility failed to store food in sealed containers. The facility failed to keep bottles free of dry drippings. The facility failed to store food above the floor in the walk-in freezer. These failures could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs for one (Resident #23) of 24 residents reviewed for accommodation of needs. Resident #23's call light was not within reach and was difficult for him to use. This failure could place residents at risk of not being able to call for assistance when needed.

Inspectors wroteBased on interview and record review the facility failed to ensure that a resident with limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 (Resident #111) of 7 residents reviewed for treatment and services related to range of motion. The facility failed to ensure that Resident #111 received services to increase or maintain his range of motion. This failure could put residents at risk of decreased range of motion, decreased quality of life, and increased risk of contractures and threats to skin integrity.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 2 of 12 residents (Resident #103 and Resident #15) reviewed for supervision and accidents in that: CNA A and NA B transferred Resident #103 from his wheelchair to the bed by grabbing him from the back of his pants and his under arms. The fall mat for Resident # 15 was far away from his bed. These failures could put residents at risk of accidents and serious injuries which could result in a reduced quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who is fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #111) of 4 residents reviewed for feeding by enteral means. The facility failed to ensure that Resident #111's enteral feeding formula was properly labeled. This failure put residents at risk of not receiving adequate nutrition by way of enteral feeding.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care consistent with the comprehensive person-centered care plan, the resident's goals and preferences for 1 of 8 (Resident #19) residents reviewed for respiratory care. The facility failed to ensure Resident #19 had her nasal cannula on per physicians' orders.

Inspectors wroteBased on observations and interviews, the facility failed to dispose of garbage and refuse properly for 1 barrel of used cooking oil outside of the facility. One barrel used to dispose of used cooking oil was open without a lid and it had trash inside. This failure could place residents at risk of decreased quality of life due to an exterior environment which could attract pests, rodents, and other animals.

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 to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #25) of 12 residents reviewed for infection control in that: NA B failed to wash her hands and change her gloves after they became contaminated during incontinent care while assisting Resident #25. These failures could place resident's risk for cross contamination and the spread of infection.

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 1 kitchen reviewed for safe operating equipment in safe operating condition. The facility failed to maintain the stove in operational condition. This failure could place residents at risk of foodborne illnesses; and potential for injury to residents and staff by not maintaining essential equipment in safe operating condition.

Inspectors wroteBased on interviews and record review the facility failed to electronically transmit within 14 days after the facility completed a resident's assessment, encoded MDS data including a subset of items upon a resident's transfer, reentry, discharge, and death for 5 (Residents #2, #201, #104, #92 and #74) of 6 residents reviewed for electronic transmission of MDS data to the CMS system. The facility failed to transmit discharge MDS data to the CMS system for Residents #2, #201, #104, #92 and #74 within 14 days of Resident s discharge from the facility. This failure could place residents at risk of not having specific information transmitted in a timely manner.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 10 residents reviewed for missing person. The facility failed to provide supervision to prevent accidents for Resident #1 who exited the building on 4/19/24 and was left to sleep outside overnight. This failure placed Resident #1 at risk of insect bites, a fall, and weather exposure, which could result in injuries, hospitalization, or death. The noncompliance was identified as PNC. The IJ began on 4/19/24 and ended 04/22/24. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards as is possible and each resident receives adequate supervision to prevent accidents for 1 (Resident #8) of 8 residents and 1 Employee Lounge of 1 reviewed for accidents. 1. Resident #8 was placed 1:1 supervision for hitting a prior resident and Lead CNA left Resident #8 to go assist another staff and did not ensure another nursing staff member was 1:1 with Resident #8 that lead to Resident #8 hitting another Resident #9. This failure was determined to be past non-compliance on 03/22/24 and ended 03/22/24 the facility implemented action that corrected the non-compliance prior to the beginning of the investigation. 2. The facility Employee Lounge door was left open for anyone to enter the employee lounge. [...]

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 1 (Hall 100 Nurse station trash can) of 4 trash cans and 1 (Housekeeper ) of 1 Housekeepers reviewed for infection control in that: The hall 100 nurse station trash can was overflowing with trash and it was on the ground. The sick Housekeeper did not follow the Covid policy by calling work to find out if she had to go into work. As stated by the DON stated, anyone feeling sick before work needs to call into work to let someone know they are not feeling well. The Housekeeper failed to follow the employee lounge warning sign of, keep door closed, when she exited the employee lounge. [...]

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 promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 1 (Resident #2) of 3 residents reviewed for dignity. Resident #2 did not have a privacy bag on his catheter bag. This failure could place residents at risk of diminished quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to coordinate the assessment following the PASRR Completion PCSP for 1 (Resident #8) of 2 residents with the pre-admission screening and resident review (PASRR) program, of resident assessments reviewed for PASRR services. The facility to provide PASRR services for Resident #8 who was PASRR positive for intellectual disabilities by not submitting a request to the state agency for PASRR services. This failure could affect residents who are PASRR positive of not receiving needed PASRR services which could lead to a decline in health and well-being.

Inspectors wroteBased on observation, interview, and 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 promote healing and prevent worsening of pressure injuries for 2 (Resident #6 and Resident #3) of 2 residents reviewed for wound care. The Wound Care Nurse grabbed a gaze without gloves and placed it into a clear cup that was soaked in betadine and then used it to provide wound care for Resident #6 who had a right lateral foot wound. The Wound Care Nurse did not date or initial Resident #3's patches after providing wound care. This deficient practice could place residents at risk for worsening pressure injuries, pain, and a decline in health.

Inspectors wroteBased on the interview and record review the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in uniform form format according to specifications established by CMS for 1 of 4 quarters (1st Quarter October 1, 2022 to December 31, 2022) reviewed for administration (Fiscal year 2023, for the first quarter October 1, 2022, to December 31, 2022). The facility failed to submit PBJ (Payroll Based Journal) staffing information to CMS for the 1st quarter of the fiscal year 2023. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents choices for 2 of 7 (Resident #4 and Resident #5) reviewed for quality of care. The facility failed to complete one quarterly fall assessment for Resident #4. The facility failed to complete two quarterly and/or readmission fall assessments for Resident #5. These failures could place residents at risk for diminished quality of care.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 3 (Resident #3, #4, and #7) of 10 residents reviewed for comprehensive care plans. 1. The interdisciplinary team failed to have a care plan in place for Resident #3 refusing to be repositioned. 2. The interdisciplinary team failed to have care plans in place for urinary catheters for Residents #4 and #7. These failures could place residents at risk of not having their catheter care needs met and not having a consistent approach to addressing behavioral issues.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 6 (Residents #3, #4, #5, #6, #8, and #10) of 8 residents reviewed for indwelling catheters, in that: -The facility failed to ensure Residents #3, #4, #5, #6, #8, and #10 foley bags were kept off the floor. -The facility failed to ensure Resident #8's foley bag was kept out of the trash can. - The facility failed to obtain orders to provide urinary catheter care for Residents #2, #4, #6 and #7 who had urinary catheters in place. These failures could place residents at risk for urinary tract infections.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to ensure accurate administration and documentation of medications for 2 residents (Residents #1 and #3) of 10 reviewed for pharmacy services and medication administration in that: The facility failed to obtain and administer Advair Diskus or Fluticasone Propionate (breathing treatments) to Resident #1 as prescribed. The facility failed to obtain orders to hold Levimir (a diabetic medication) for Resident #3 when her blood sugars were low. This failure placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health due to not having orders for diabetic medication and respiratory treatments administered as ordered.

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 or ensure standard and transmission-based precautions were followed to prevent spread of infections for 6 (Residents #1, #3, #4, #5, #8, and #10) of 10 residents reviewed for infection control, and failed to report a newly detected case of COVID-19 for one resident (Resident #9) of 10 residents reviewed for accurate reporting of communicable diseases. 1. The facility failed to report Resident #9's diagnosis of COVID-19 detected on 12/17/2023 until 12/22/2023 (5 days) 2. The facility failed to ensure Residents #3, #4, #5, #8, and #10 foley bags were kept off the floor. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to implement COVID-19 immunizations policies and procedures to ensure that resident's medical record includes documentation that indicates that the resident or resident representative was offered provided education regarding the benefits and potential risks associated with COVID-19 vaccine for 6 (Residents #1, #4, #6, #7, #9 and #10) of 10 residents reviewed for COVID-19 vaccination status. The facility failed to provide documentation that Residents #1, #4, #6, #7, #9 and #10 or their representatives had received education regarding the benefits and potential risks associated with COVID-19 vaccine. These failures placed residents at risk for infections, the transmission of infectious disease, and a decline in health status.

Inspectors wroteBased on interview and record review the facility failed to develop and implement comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident medical and nursing needs to be furnished to attain or maintain the residents highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Resident #1) reviewed for care plans in that: The facility failed to develop and implement a comprehensive person-centered care plan for Resident #1's transfer for activities of daily living. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services and having personalized plans developed to address their needs.

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 1 of 4 (Clean Linen Closet in hall 100 ) closets reviewed for infection control in that: - The clean linen closet door in hall 100 was propped open by a white towel and not securely closed. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records that were accurately documented for 3 (Resident #4, Resident #8, and Resident #9) of 15 residents reviewed for clinical records. -The facility failed to document administration of Tramadol on several shifts in Resident #4, Resident #8 and Resident #9's clinical records. This failure could cause an effect in residents if more doses of medication were to be given based on inaccurate documentation of medication administration.

Inspectors wroteBased on observations, interviews, 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 room (room [ROOM NUMBER]) of 12 rooms reviewed for infection control in that: 1. The facility failed to ensure CNA A provided care in COVID positive room [ROOM NUMBER] with proper PPE. This deficient practice could cause the spread of disease and cross contamination in the facility.

Inspectors wroteBased on interviews and record reviews, the facility failed to send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman for 1 resident (Resident #11) of 1 reviewed for discharges. -The facility failed to provide an immediate discharge notice to Resident #11 and failed to notify to the State Ombudsman. This failure could place residents at risk of being wrongfully discharged if the process for discharge is not followed.

Inspectors wroteBased on observation, 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 1 of 8 (Resident #7) residents reviewed for base line care plans. The facility failed to develop a baseline care plan for Resident #7. This failure could put residents newly admitted at risk of needs not being identified affecting the quality of care they receive.

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 of each resident, encouraging both independence and interaction in the community for 1 of 8 (Resident #7) residents reviewed for individual activities. The facility failed to provide Resident #7 with a word search to work on individually in her room per her preference. This failure could result in residents being bored resulting in a diminished quality of life. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure nurse staffing data was posted and readily accessible to residents and visitors for one of twenty-six days reviewed for nurse staffing information. The facility failed to post the required staffing information for September, 09/26/2023. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on the observations, interviews, and record reviews the facility failed to ensure that the residents environment remains free of accidents hazards as possible and ensure each resident receives adequate supervision to prevent accidents for 3 (Residents #22, Resident #8 & Resident #35) of 24 residents reviewed for accidents. 1. The facility failed to make sure Resident #22 had preventive measures added when Resident #22 got her hand stuck between PVC pipe of the bed that reulted in a fractured right thumb and despite the injury the facility took no steps to prevent future injuries. 2. The plastic arm of Resident #8's wheelchair was torn and exposed. 3. The plastic on the arms of Resident #35's wheelchair was torn and sticking up. [...]

Inspectors wroteBased on, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 5 (Resident #114, Resident #58, Resident #4, Resident #37 and Resident #41) of 15 residents observed for assistance with ADL's. The facility failed to ensure facility staff provided showers to maintain good grooming, personal and oral hygiene for Resident #114, Resident #58, Resident #4, and Resident #41. The facility failed to ensure staff helped resident #37 to the bathroom in a timely manner resulting in him having to urinate in his brief. This deficient practice could affect residents who were dependent on assistance with ADL's and could result in poor care, skin breakdown, feelings of poor self-esteem, and lack of dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who was fed by enteral means receives the appropriate treatment and services for 3 of 10 residents (Resident #12, Resident #22 and Resident #70) reviewed for enteral feeding. 1. Resident 12's enteral feeding bag labels did not have the rate of administration, the initials of nurse, amount, and expiration date. The feeding pump did not correctly reflect the amount of formula that had been delivered to the resident. 2. Resident #22's feeding tube valve was not clean as it was dirty. 3. Resident #70's bag of tube feeding formula did not have the rate of administration, the initials of nurse, amount, and expiration date. These failures could place residents receiving enteral feedings at risk of insufficient nutritional supplementation and possible weight loss.

Inspectors wroteBased on observation , interview, and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice for 1 (Resident #271) of 10 residents observed for oxygen management. 1. Resident #271 was using oxygen while his Room (room [ROOM NUMBER]) and did not have an oxygen sign posted outside his bedroom. This failure could place residents on oxygen therapy at risk of a hazard and inappropriate care.

Inspectors wroteBased on interview and record review the facility failed to ensure that there were 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 eight residents who attended a confidential group meeting, and for 5 (Resident #114, Resident #58, Resident #4, Resident #37, and Resident #41) of 15 residents reviewed for assistance with ADL's. 1. The facility was short of CNA FTEs (Full-time equivalents) on 39 of 51 days reviewed for CNA Per Patient Days 2. [...]

Inspectors wroteBased on observation and interview the facility failed to store food in accordance with professional standards for food service safety for one of one kitchen observed for safe food storage. Observation of the facility kitchen included: - A large container of salsa was not labeled. - A container of noodle soup was mislabeled and expired. - A tray of individually wrapped peanut butter and jelly sandwiches had no label on the sandwiches or the tray. This failure could put residents at increased risk of food-borne illness.

Inspectors wroteBased on interview and record review the facility failed to notify the ombudsman of the transfer or discharge and the reasons for the transfer/discharge in writing and in a language and manner they understood for 1 (Resident #116) of 4 Residents reviewed for transfer/discharge. The facility did not send a written discharge notice to the state's long term care ombudsman of the effective date of transfer or discharge, the reason for the transfer/discharge, or the right to appeal. This deficient practice could affect residents at the facility at risk of having their discharge rights violated.

Inspectors wroteBased on, interview, and record review the facility failed to ensure that new residents with mental disorder were provided with a PASRR Level II Screening for one resident (Resident #43) of 5 residents reviewed for PASARR coordination. - The facility failed to notify the local authority when a PASSR 1 for Resident #43 indicated a positive MI status, a PASRR Level II evaluation was not completed. This failure put residents with mental illness at risk of at risk of not receiving appropriate care and services from the local authority, which could result in failure to maintain or a possible decline in mental health.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide an ongoing program of facility sponsored activities designed to meet the mental well-being of 1 (Resident #22) of 6 residents reviewed for facility activities. The facility failed to provide activities program to meet the needs of Resident #22. This failure could result in residents decreased physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, 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) for 1 of 2 medication carts (100 Hall) reviewed for expired medications. -100 hall medication cart had expired medication. This deficient practice could cause a decline in health in residents if expired medication was to be given.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that a PRN order for psychotropic drugs was limited to 14 days and if the attending physician believed that it was appropriate for the PRN order to be extended beyond 14 days, failed to document their rationale for 1 resident (Resident #114) of 3 reviewed for psychoactive medications in that: The facility failed to ensure that Resident #114 had an order for psychotropic medication (Haldol) that did not contain PRN orders beyond 14 days without an end date. This deficient practice could place residents at risk of receiving unnecessary medication and adverse drug reactions.