Avir at Rose Trail

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from abuse, neglect, misappropriation of resident property and exploitation for 2 of 10 residents (Resident #1 and Resident #2) reviewed for misappropriation of funds. The facility failed to ensure CNA/Staffing Coordinator B did not take money from Resident #1 and Resident #2 for her personal use. This failure could place residents at risk for decreased quality of life and misappropriation of funds.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were 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 cause the suspicion do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for 2 of 10 residents (Resident #1 and Resident #2) reviewed for reporting misappropriation of property. [...]

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 and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were 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 cause the suspicion do not result in serious bodily injury to the administrator of the facility and to other officials, including to the State Survey Agency, in accordance with State law through established procedures for four of eight (Resident #1, Resident #2, Resident #3, and Resident #4) residents reviewed for abuse and neglect. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 was administered his evening dose of apixaban (also known under the brand name Eliquis, an anticoagulant medication used to treat and prevent blood clots) on 1/1/26 and his morning dose (of apixaban) on 1/2/26. This failure could place residents at risk of not receiving the therapeutic effect of medications used to treat significant medical diagnosis and could result in significant health complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality of his or her personal and medical records for 10 (Residents #1, #2, #3, #4, #5, #6, #7, #8, #9, and #10) of 13 residents reviewed for privacy and confidentiality. 1. The facility failed to ensure the care plan for Residents #1, #2, #5 and #6 was not left in the public survey binder in the lobby of the facility. 2. The facility failed to ensure the PIR that contained the SSN and PHI of Residents #3 and #4 was not left in the public survey binder in the lobby of the facility. 3. The facility failed to ensure that the Resident Identifier sheet and corresponding survey containing PHI of Residents #7, #8, #9, and #10 were not left in the public survey binder in the lobby of the facility. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 main facility kitchen. The facility failed to ensure a stainless steel sheet pan was clean and free of heavy carbon build-up. The facility failed to ensure food packaging in the dry pantry was sealed after opening. The facility failed to ensure the microwave was clean. The facility failed to ensure food items were labeled or dated. The facility failed to ensure scoops were not present in the bulk sugar container. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

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 3 residents (Resident #5, Resident #62, and Resident #72) reviewed for infection control. The facility failed to ensure CNAs E and F wore PPE when providing ADL care to Resident #72. The facility failed to ensure RN D wore PPE when providing tracheostomy care to Resident #5. The facility failed to ensure RN D wore PPE when providing enteral feeding to Resident #62. These failures could place residents at risk for cross contamination, spread of infection and sepsis, in violation of infection prevention and control requirements.

Inspectors wroteBased on interviews and record review, the facility failed to treat each resident with respect and dignity and cared for in a manner and environment that promoted the maintenance and /or enhancement of quality of life for 1 of 5 residents (Resident #6) reviewed for dignity and respect. LVN-H handled the Resident # 6's oxygen nasal cannula in a rough and abrupt manner, slapped it against the bed, and displayed frustration, demonstrating unprofessional conduct that did not promote the resident's quality of life. This failure has the potential to impact on the dignity of residents in the facility by causing residents to feel intimidated, threatened, or degraded.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with a diagnosis of mental illness were provided an accurate Preadmission Screening and Resident Review Level 1 (PASARR) Screening for 1 of 5 residents reviewed for PASARR (Resident #71). The facility failed to ensure that Resident #71 had an accurate PASARR Level 1 Screening indicating a diagnosis of mental illness on 06/24/2025. This failure could place residents at risk of not receiving needed assessments (PASARR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to develop a baseline care plan within 48 hours of admission and provide the resident and or the resident representative with a summary of the baseline care plan for 1 of 5 residents reviewed for the base line care plans. (Resident #90) The facility did not complete a baseline care plan within 48 hours of admission and provide a written summary of the baseline care plan to Resident #90 or their responsible party. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on observations, 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 time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 2 of 4 residents (Resident #34 and Resident #71) reviewed for care plans. 1. The facility failed to ensure that Resident #34's care plan included interventions for sexually inappropriate behavior. 2. The facility failed to ensure that Resident #71's care plan reflected the physician's order and intervention of enteral feedings. These failures could place residents at an increased risk of decline in physical or functional well-being, of not receiving necessary care or services, and having personalized plans developed/implemented to address their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan and the residents goals and preferences for 1 of 2 residents (Resident #60) reviewed for oxygen therapy, in that: Resident #60's oxygen was set to 3.5 LPM on 3 consecutive days instead of 2 LPM as ordered by the physician. Resident #60's medical record did not include documentation of oxygen saturation checks and oxygen administration. These failures could place residents who receive oxygen therapy at risk for respiratory distress and incomplete medical records.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 2 of 5 residents (Resident #61 and Resident #74) reviewed for pharmacy services. MA-A failed to take action to acquire Resident #61s scheduled dose of Pantoprazole when she did not have it available for administration. MA-A failed to take action to acquire Resident #74's scheduled dose of Tegretol when she did not have it available for administration. MA-A incorrectly documented she administered a dose of Pantoprazole to Resident #61 and a dose of Tegretol to Resident #74 when she did not have the 2 (two) medications available for administration. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less than 5 percent. There were 2 errors out of 27 opportunities, resulting in a 7 percent medication error rate involving 2 of 5 residents (Resident #61 and Resident #74). MA-A failed to administer a scheduled medication, pantoprazole 40 MG tablet, to Resident #61 as ordered by the physician. MA-A failed to administer a scheduled medication, Tegretol 300 MG tablet, to Resident #74 as ordered by the physician. These failures could place residents at risk of not receiving the therapeutic effects of the mediations and could result in a decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #74) reviewed for significant medication errors. MA-A failed to take action to acquire and administer a scheduled medication, Tegretol (to prevent seizures related to diagnosis of epilepsy). This failure could place resident at risk of not receiving the therapeutic effect of mediations and could result in a decline in health status.

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 residents that meet professional standards of quality care within 48 hours of the residents' admission for 2 of 2 residents (Resident #1, Resident #2). The facility failed to ensure Resident #1, and Resident #2 had a baseline care plan. This failure could place residents at risk for not communicating appropriate treatment and services to meet their needs.

Inspectors wroteBased on observation, interviews and records reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to ensure the comprehensive care plan described the services and interventions to be used to attain and maintain the resident's practicable physical, mental, and psychosocial well-being for 4 of 4 residents reviewed for care plans (Resident #1, Resident #2 Resident #3, and Resident #4). The facility failed to ensure Residents 1, 2, 3, and 4 had documented a completed Comprehensive Care Plan. This failure could place residents at risk for not communicating appropriate treatment and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide respiratory care, including tracheostomy care and tracheal suctioning consistent with professional standards of practice, the resident's care plan, and the resident's preferences, for 2 of 3 residents (Resident #1 and Resident #2) reviewed for respiratory care. The facility failed to ensure LVN C assessed Resident #1 when he exhibited abdominal retractions (a sign of respiratory distress) while breathing on 09/24/25. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. The facility failed to follow the tracheotomy care and suctioning policy and procedure. [...]

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 5 of 5 residents (Resident's #1, # 2, #3) reviewed for infection control practices. The facility failed to ensure LVN A, LVN C, LVN D, and the Interim DON used sterile technique while performing tracheotomy suctioning on Resident #1. The facility failed to ensure RN B used sterile technique while performing tracheotomy care on Resident #2 on 09/29/25. The facility failed to follow the tracheotomy care and suctioning policy and procedure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that all alleged violations involving abuse, or mistreatment were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 4 residents (Resident #7 and Resident #6) reviewed for abuse and neglect. The facility failed to report to Health and Human Services Commission an alleged incident of verbal abuse by Resident #6 towards Resident #7 on or about 07/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 residents (Resident #4) reviewed for care plans. The facility failed to ensure a care plan was developed and implemented for Resident #4's use of a Foley catheter and leg band strap stabilizer. These failures could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 8 residents (Resident #1 and Resident #4) reviewed for treatment and services related to indwelling catheters. 1. The facility failed to ensure Resident #1's foley catheter was secured on 09/11/2025. 2. The facility failed to ensure Resident #4 foley catheter was secured on 09/27/25, 09/28/25, 09/29/25, and 10/02/25. These failures could place residents at risk for urinary tract infections, dislodgment, potential complications and a decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remained free of accidents hazards and each resident was provided adequate supervision to prevent elopement for 1 of 3 residents (Resident #1) reviewed for accident hazards. The facility failed to provide appropriate supervision to Resident #1 on 8/10/25 when she was exhibiting exit seeking behavior resulting in her elopement between 5:45 p.m. and 6:00 p.m. with Resident #1 being returned to the facility by local police on 8/10/25 at approximately 7:15 p.m. The noncompliance was identified as PNC IJ. The noncompliance began on 8/10/2025 and ended on 8/11/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of suffering heat related illness or injury or death. Findings Include: [...]

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy (an opening through the neck into the trachea to provide and airway) care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #2) reviewed for tracheostomy care. The facility failed to ensure Resident #2 had replacement tracheostomy supplies (tracheostomy tubes (a curved tube inserted into the tracheostomy to keep the airway open)) in the facility or at the bedside. This failure could place residents at risk of respiratory distress and prolong emergency care being provided.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical needs for 1 of 6 residents (Resident #3) reviewed for care plans. The facility failed to ensure Resident #3's care plan was updated when she completed her vitamin C, multivitamin with minerals, and zinc (supplements for wound care). This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings Included: 1. Record review of the face sheet dated 3/25/25 indicated Resident #3 was admitted to the facility on [DATE] with diagnoses including pressure ulcer of the sacral region, dementia, and multiple sclerosis (a disease in which the immune system eats away at the protective covering of the nerves). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 4 (Resident #1) reviewed for pressure injuries. The facility failed to ensure Resident #1's dressing to her sacrum was changed/re-applied after becoming saturated or dislodged per physician orders. This failure could place residents at risk for new development or worsening of existing pressure injuries, pain, and decreased quality of life.

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 2 of 3 residents (Resident #1 and #2) and 1 of 4 staff (Treatment Nurse) observed for infection control. The facility failed to ensure the Treatment Nurse changed gloves and performed hand hygiene while performing wound care and incontinent care on Resident #1 and Resident #2. This failure could place residents and staff at risk for cross-contamination, spread of infection, and could potentially affect all others in the building. Findings Included: 1. During an observation on 3/25/25 at 8:56 a.m. the Treatment Nurse performed wound care and incontinent care on Resident #1 with assistance from CNA A. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure accurate MDS assessments were completed for 4 of 6 Residents (#16, #50, #60, #61) reviewed for accuracy of MDS assessments. The facility failed to accurately code Residents #16's and #50's quarterly MDS assessments for dialysis. The facility incorrectly coded Residents # 60's and #61's comprehensive MDS assessments for ventilator use. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 3 of 5 residents reviewed for pharmacy services (Residents #45, #57, and #173). The facility failed to ensure the physician's order for Vitamin C included the dose of Vitamin C to be administered to Resident #45. The facility failed to ensure three (3) physician prescribed medications including Vitamin B12 (a vitamin present in foods of animal origin), Brimonidine tartrate ophthalmic (refers to the eye) solution (eye drops to treat glaucoma, a condition wherein the nerve connecting the eye to the brain is damaged and can result in blindness)), and Latanoprost ophthalmic eye drops (to treat glaucoma) were available for administration to Resident #57 as ordered by the physician. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review Level 1(PASRR) Screening for 2 of 5 residents reviewed for PASRR (Resident #36 and #57). The facility failed to ensure Resident #36 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 9/20/2021. The facility failed to ensure Resident #57 had an accurate PASRR Level 1 Screening indicating a diagnosis of mental illness on 5/10/2023. These failures could place residents at risk of not receiving needed assessments (PASRR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate less that 5 percent. There were 3 errors out of 31 opportunities, resulting in a 9 percent medication error rate involving 2 of 4 residents (Residents #45 and #57) reviewed for medication administration. MA C administered Vitamin C to Resident #45 without verifying the dose to be given. RN D failed to administer Vitamin B12 and Brimonidine ophthalmic solution 2% to Resident # 57 as ordered by the physician. These failures could place residents at risk for inaccurate drug administration resulting in a decline in health and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement infection prevention and control practices 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 (Residents #57) reviewed for medication administration procedures. RN D obtained a syringe sealed in a plastic bag from the floor of Resident #57's room and used it for administration of water and medications through a gastrostomy tube after contaminating the syringe plunger by placing it on the plastic bag that had been lying on the floor. This failure could place residents who receive medications, water, or liquid nutrition via a gastrostomy tube at risk for exposure to possible transmission of communicable diseases and infections.

Inspectors wroteBased on interview and record review the facility failed to provide or obtain laboratory services to meet the needs of residents for 1 of 5 residents (Resident #1) reviewed for laboratory services. The facility did not obtain UA labs as ordered by the physician for Resident #1. This failure could place residents at risk of not receiving treatment and services to meet their needs.

Inspectors wroteBased on record review and interview, the facility with more than 120 beds failed to employ a qualified social worker on a full-time basis for 1 of 1 facility reviewed for social worker qualifications. The facility did not have a qualified social worker since May 05/10/2024. This failure could affect residents in need of social services and place them at risk of psycho-social decline and poor-quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for 1 (Resident #1) of 7 residents reviewed for abuse and/or neglect. The facility failed to prevent CNA B from physically abuse abusing Resident #1 when she slapped her arm and left a bruise. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have evidence that all alleged violations were thoroughly investigated for 1 of 7 residents (Resident #2) reviewed for abuse and neglect. The facility failed to conduct a thorough investigation when Resident #2 alleged LVN A slapped at her hand and cursed at her during wound care. This failure could place residents at risk of abuse and neglect.

Inspectors wroteBased on 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 7 (Resident #1) residents reviewed for quality of care. 1. The facility failed to provide wound care to Resident #1's right lower extremity stump (the remaining part of the right leg after amputation) as ordered resulting in infection and surgical debridement (the removal of damaged tissues from a wound) to rule out osteomyelitis (inflammation of the bone caused by infection). 2. The facility failed to report redness to Resident #1's abdomen to the Nurse Practitioner or Wound Care Physician resulting in hospitalization related to cellulitis (bacterial skin infection) and panniculitis (inflammation of the subcutaneous fat) requiring intravenous (IV) antibiotics. 3. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and pain for 1 of 7 (Resident #2) residents reviewed for urinary catheters. The facility did not ensure Resident #2's urinary catheter (a tube inserted into the bladder to drain urine) bag was not lying in the floor . This failure could place residents at risk for urinary catheter bags busting by being stepped on or wheeled over by a wheelchair allowing bacteria into the catheter tubing, pain, and infection.

Inspectors wroteBased on interview and record review the facility failed to ensure a discharge was appropriately communicated and documented in the medical record for 1 of 4 discharged residents (Resident #1) reviewed for discharge requirements. 1. The facility refused to re-admit Resident #1 from the hospital on 2/22/2024. 2. Resident #1's clinical record had no physician documentation to address why the resident was being discharged , what needs of the resident the facility could not meet, and how the resident posed a danger to the existing resident population. These failures could place residents at risk of not receiving the necessary care and services to meet their physical and psychological needs.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for 1 of 4 residents (Residents #1) reviewed for transfer and discharge. The facility initiated a discharge for Resident #1 due to a change of condition and did not notify the State Long-Term Care Ombudsman by phone or in writing. This failure could place residents at risk of improper discharge planning and diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to establish and follow written policy on permitting residents to return to the facility after they were hospitalized for 1 (Resident #1) of 4 residents reviewed for transfer/discharge. 1. The facility failed to admit Resident #1 back to facility after he was sent to the hospital on [DATE]. 2. The facility failed to give Resident #1 a 30-day discharge notice. These failures could place residents at risk of not receiving the care and services to meet their needs and could affect their mental and emotional well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 12 residents (Resident #1, Resident #2, and Resident #4) reviewed for infection control. 1. The facility failed to ensure a resident COVID-19 outbreak that included one hospitalization, Resident #4, was reported to state regulatory authority. 2. The facility failed to ensure the OTA G, CNA D, and PT R maintained proper donning of facemasks for source control in the hallway and within 3 feet of Resident #1 and Resident #2 during a COVID-19 outbreak. These failures could place residents at risk for development and spread of infection.

Inspectors wroteBased on interview and record review, the residents have the right to be free from abuse, neglect, misappropriation of resident property, and exploitation and the facility failed to ensure residents were free from Abuse, Neglect, and Exploitation for 2 of 8 residents reviewed for abuse. (Residents #1 and #2) The facility failed to ensure Resident #1 and Resident #2 were free from abuse and failed to implement their written policies and procedures that prohibited and prevented abuse, which resulted in Resident #1 stabbing his roommate Resident #2 with a pocket knife during a physical altercation and Resident #2 sustained multiple stab marks (non-invasive, and barely breaking skin) to right side of the chest and laceration to Resident #2's right hand that required stiches. This failure could place the residents at risk for increased risk for abuse and neglect.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for 2 of 8 residents reviewed for accidents. (Residents #1 and #2). The facility failed to provide adequate supervision which resulted in Resident #1 stabbing his roommate Resident #2 with a pocketknife during a physical altercation and Resident #2 sustained multiple stab marks (non-invasive, and barely breaking skin) to right side of the chest and laceration to Resident #2's right hand that required stiches. This failure could place residents at risk for abuse and a diminished quality of life.

Inspectors wroteBased on interview and record review the facility failed to maintain evidence demonstrating the result of all grievances for a period of no less than 3 years from the issuance of the grievance decision for 1 of 1 grievance book reviewed for clinical records. The facility failed to follow their policy and maintain the grievance records for a period of no less than 3 years from January 2020 to October 31, 2023. This failure could place residents at risk for unresolved grievances which could lead to miscommunication, a delay in services or a potential decline in resident 's health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to assist residents in obtaining routine and emergency dental care for 2 of 7 (Resident #1 and Resident #2) residents reviewed for dental services. The facility failed to provide emergency dental services for Resident #1 after complaints of mouth pain, orders for dental referrals were received, and being prescribed antibiotics for a mouth infection. The facility failed to provide dental services for Resident #2's broken teeth. This failure could affect residents by placing them at risk for oral complications and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 2 of 7 (Resident #1 and Resident #2) residents reviewed for MDS assessment accuracy. The facility failed to accurately reflect Resident #1 and Resident #2's dental oral/dental on the MDS assessment. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights for 1 of 7 (Resident #1) residents reviewed for care plans, The facility failed to ensure Resident #1's oral/dental health problems were care planned prior to surveyor intervention. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. 1. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 2 of 5 residents (Resident #1 and Resident #2) reviewed for resident rights. The facility did not ensure Resident #1 and Resident #2's catheter bag (urine reservoir bag) had a privacy bag in place. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 2 of 5 residents (Resident #1 and Resident #2) reviewed appropriate treatment and services related to indwelling catheters. The facility failed to ensure Resident #1's catheter bag was placed below the level of the bladder. The facility failed to ensure Resident #1's catheter bag and catheter tubing was kept off the floor. The facility failed to ensure Resident #1 had a catheter secure device in place. The facility failed to ensure Resident #1 and Resident #2's catheter tubing was free of dependent loops (a configuration of catheter tubing where the drainage tubing dips below the entry point into the catheter bag). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the appropriate treatment and services to prevent complications was provided for 1 of 2 residents reviewed for feeding tube management. (Resident #3) The facility did not ensure Resident #3 had his dressing removed/changed around his gastrostomy tube site after his return from the hospital and did not assess the site as ordered. These failures could place residents with gastrostomy tubes at risk for skin irritation, insertion site infections and associated complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from abuse for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse. The facility failed to protect Resident #1 and Resident #2 from verbal and physical abuse by CNA B. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 8/11/23 at 4:15 p.m. While the IJ was removed on 8/13/23, the facility remained out of compliance at no actual harm that is not immediate with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place residents at risk for physical and verbal abuse, psychosocial harm, and decreased quality of life. Findings Included: 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to implement written policies to prevent abuse, neglect, and exploitation for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse. The facility did not follow facility policy by suspending or removing the CNA B from the premises after allegations of abuse were made. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 8/11/23 at 4:15 p.m. While the IJ was removed on 8/13/23, the facility remained out of compliance at no actual harm that is not immediate with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. This failure could place the resident at risk for unreported allegations of abuse, neglect, and injuries of unknown origin, and further abuse by the alleged perpetrator.

Inspectors wroteBased on interview, and record review, the facility failed to investigate allegations of abuse and prevent further potential abuse for 2 of 7 (Resident #1 and Resident #2) reviewed for abuse investigations. The facility failed to investigate allegation of physical and verbal abuse to Resident #1 and Resident #2 from CNA B. The facility failed to remove the alleged perpetrator (CNA B) from the facility to protect the residents from abuse. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 8/11/23 at 4:15 p.m. While the IJ was removed on 8/13/23, the facility remained out of compliance at no actual harm that is not immediate jeopardy with a scope identified as isolated due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective systems. [...]

Inspectors wroteBased on observation, interview, and record review the facility, failed to ensure sure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in the central bath and 8 of 35 resident rooms (106, 211,226,.227,.228,.229,315 and 329) reviewed for environment., The facility failed to ensure resident used common areas and rooms were clean and did not need repair. These failures could place residents at risk for living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an accurate MDS was completed for 6 of 12 residents (Residents #9, 25, 33, 50, 94, and 97) reviewed for MDS assessment accuracy. The facility did not accurately code Resident #9's quarterly MDS assessment for assistance with eating and diuretic use. The facility did not accurately code Resident # 25's annual MDS assessment for antipsychotic medication use. The facility did not accurately code Resident #33's annual MDS assessment for Pressure Ulcer and insulin use, opioid use, antidepressant use, antibiotic use, and antianxiety use. The facility did not accurately code Resident #50's quarterly MDS assessment for assistance with eating and diuretic use, opioid use, antidepressant use, and anticoagulant use. The facility did not accurately code Resident #94's quarterly MDS assessment for antipsychotic use. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene that promotes maintenance or enhancement of his or her quality of life, for Resident (Resident #34) review for activities of daily living The facility failed to provide Resident #34 with personal grooming for nail care These failures could place residents at risk for poor hygiene, dignity issues and decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse and neglect. The facility did not report the allegations of verbal and physical abuse of Resident #1 and Resident #2 by CNA B to the state agency. This failure could place residents at risk of injuries, abuse, and/or neglect. Findings Include: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to electronically transmit encoded, accurate, and complete MDS data to the CMS System within 14 days after the facility completed the resident's assessment for 2 of 2 residents reviewed for MDS assessments. (Resident #32 and 65) The facility failed to transmit to the CMS system Resident #32 's discharge MDS assessment dated [DATE]. The facility failed to transmit to the CMS system Resident #65 's discharge MDS assessment dated [DATE]. This failure could place the residents at risk for not having the MDS assessment transmitted as required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the daily nurse staffing data at the beginning of the shift, in a prominent place, and readily accessible to residents and visitors that included the facility name, the number and actual hours worked by licensed and unlicensed nursing staff directly responsible for resident care for 4 of 4 days reviewed for nurse staffing data. The facility failed to post the required nurse staffing information 08/14/2023, 08/15/2023, 08/16/2023, and 08/17/2023. This failure could place residents and visitors at risk for not having access to nurse staffing information and census.