Avir at San Knoll

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a comfortable and homelike environment including comfortable and safe temperature levels for 1 of 2 dining rooms (main dining hall). The facility failed to ensure the temperature in the main dining room was not above 81 degrees on 6/25/26, 7/21/26, and 7/24/26;The facility was not consistently monitoring the temperature in the dining room;The facility did not complete air conditioning repairs to ensure the unit was cooling properlyThis failure could place any residents at risk of living in an unsafe environment and result in feelings of dissatisfaction.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and to provide care for each resident in a manner and in an environment that promotes, maintains, or enhances his or her quality of life 2 of 2 (Resident #1 and Resident #2) residents reviewed for resident rights. The facility failed to provide a dignified and respectful dining experience for Resident #1 and Resident #2 on 6/10/2026 during feeding assistance by standing in front of them. This failure could result in the loss of dignity of residents and decreased quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to treat residents 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 for 1 of 8 (Resident #1). The facility failed to ensure Resident #1 received respect and dignity when CNA F was observed using the word exorcist via electronic monitoring. This failure could place residents at risk of psychosocial harm, feeling disrespected or uncomfortable, decreased self-esteem, impaired quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident had the right to secure and confidential personal and clinical records for 1 of 10 residents (Resident #9) reviewed for Privacy and Confidentiality. The facility failed to ensure resident clinical information was not discussed in other resident rooms and/or during electronic monitoring for Resident #9. This failure could result in residents' personal information being exposed to unauthorized individuals.

Inspectors wroteBased on interview and record review the facility failed to ensure that the resident environment remained as free of accident hazards as was possible for 1 of 5 residents (Resident #1) reviewed for mechanical lift transfers. The facility failed to ensure transfers performed using a mechanical lift were completed by two staff members as per facility policy. This deficient practice could place residents at risk of falls and or accidents causing injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (MC #1 and MC#2) reviewed for medication storage. The facility failed to ensure that MC #1 and MC #2 in public areas were locked on 5/19/26. This failure could place residents at risk of medication misuse and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to clean towels for showers for 4 of 4 (Resident #1, Resident #9, Resident #10 and Resident #12) reviewed for available linen. The facility failed to ensure Resident #9, Resident #10, and Resident #12 had clean towels available to them to shower. This failure could lead to residents feeling neglected, infection control concerns, and emotional well-being.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 4 of 4 residents (Resident #1, Resident #9, Resident #10, Resident #12) reviewed for ADL care. The facility failed to ensure that Resident #1, Resident #9, Resident #10, and Resident #12 regularly obtained showers, per resident rights. This failure could place residents at risk for altered social experiences, minimized emotional well-being, and infection control issues.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received and the facility provided food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal reviewed for palatability, attractiveness, and appetizing foods. The facility failed to provide food that was palatable and at an appetizing temperature for residents related to cold, soggy shrimp and warm coleslaw. The temperature of the items on the meal tray were not within regulated safety guidelines to ensure residents are not exposed to hazardous bacterial growth. This failure could place residents at risk of a decrease in food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 2 of 2 halls (100 and 200 halls) for room trays and 1 of 1dining room reviewed, in that:1. On 04/22/2026, the facility failed to ensure CNA A sanitized her hands between resident meal trays while passing out room trays for 2 of 2 halls.2. On 04/22/2026, the facility failed to ensure LVN C sanitized her hands between resident trays in the dining room while checking trays for accuracy and passing out trays for staff to deliver to tables for 12 of 23 residents.3. On 4/23/2026, the facility failed to ensure CNA A sanitized her hands between resident meal trays while passing out room trays for 2 of 2 halls.4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that they established and maintained identical policies and practices regarding transfer, discharge and the provision of services under the State plan for all residents regardless of payment source as well as failing to ensure the residents were free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required for 1(Resident #2) of 1 residents reviewed. The facility failed to allow and assist Resident #2 to exercise his right to discharge from the facility to an outside provider per his request. The facility failed to ensure that Resident #2's rights to be free from interference from the facility were respected. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an environment that maintained or enhanced each resident's respect and dignity for 5 of 19 residents observed in dining room. The facility failed to provide a dignified and respectful dining experience for each resident in the dining room by allowing residents to watch their tablemates eat or be fed, and/or have their meals placed in front of them but they were not able to feed themselves due to physical or mental handicaps for extended periods of time. This failure could place residents at risk of embarrassment, low self-esteem, anxiety, or potential weight loss.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure staff had successfully completed a State-approved training course for feeding assistance before feeding resident who required staff to feed them for 3 of 7 unknown residents in the dining room over 3-day period of observations. The facility did not ensure that the Administrator and the Medical Records clerk completed a state approved training course for feeding assistance before assisting residents to eat. This failure could place residents who require assistance with eating at risk of aspiration and choking.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 7 (hall 100 exit door) exit doors reviewed for accident hazards and supervision. The facility failed the ensure the exit door alarm on hall 100 was not turned off where 14 of 47 residents resided. This failure could place residents who are exit seeking at risk for elopement and possible injuries.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 residents (Resident #1) and 1 of 1 staff (LPN A) reviewed for infection control. The facility failed to ensure LPN A wore appropriate PPE for EBP during wound care for Resident #1 on 03/07/2026. This failure could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post on a daily basis and at the beginning of each shift information that included the facility name, current date, total number and actual hours worked by registered nurses, licensed practical or licensed vocational nurses, certified nurse aides directly responsible for resident care per shift and the resident census for 1 of 1 days (03/07/2026) reviewed for posting of required information. The facility failed to post the required current nurse staffing and census information on 03/07/2026 at the beginning or within two (2) hours of the beginning of shift 6:00 a.m. to 6:00 p.m. This failure could place all residents, their families, and facility visitors at risk of not having access to information regarding staffing data and the facility census.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure the resident had a right to a dignified existence, self-determination, and communication with and access to people and services inside and outside the facility for 1 resident (Resident #3) of 10 residents reviewed for dignity. The facility failed to ensure Resident #3 was checked on frequently and kept clean and dignified. This failure could affect residents who have incontinence and unsanitary behaviors and could result in diminished self-esteem.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment to receiving treatment and support for daily living safety for 1 resident (Resident #3) of 10 residents reviewed for safe and clean environment. The facility failed to ensure Resident #3's room which had urine and feces on the sticky floor was cleaned as required to provide a safe and clean environment. This failure could affect residents who have incontinence and unsanitary behaviors and could result in disease spread and accidents.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure all allegations of abuse, neglect, exploitation, or mistreatment, including injuries of unknown source and misappropriation of resident property, were reported immediately, but not later than 2 hours after the allegation was made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including 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 2 residents (Resident #1 and #2) of 10 residents reviewed for neglect and misappropriation. 1. [...]

Inspectors wroteBased on observations, interviews and record reviews, 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 for 1 resident (Resident #2) of 10 residents reviewed for care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #2 that reflected she had a colostomy and required monitoring and care. This facility failure could affect residents who require care in the facility and could result in missed or inappropriate care.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 resident (Resident #4) of 5 residents reviewed for smoking. The facility failed to ensure Resident #4 was provided with a smoking apron during a smoke break. This facility failure could affect residents who smoke at the facility and could result in injury and harm.

Inspectors wroteBased on observations, interviews, and record reviews, 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 resident (Resident #1) of 10 residents reviewed for pharmaceutical services. The facility failed to ensure Resident #1's Tramadol and Tylenol #3 were accounted for when he left to go out on pass on Thanksgiving (11/27/2025). This facility failure could affect residents who take narcotics for pain and could result in misappropriation of medications or drug diversion.

Inspectors wroteBased on observations, interviews and record reviews, 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 resident (Resident #2) of 10 residents reviewed for infection control. The facility failed to ensure Resident #2 had EBP implemented when she was admitted to the facility on [DATE] with a stage 4 wound to her coccyx which required treatment and dressing. This facility failure could affect residents with wounds and could result in cross contamination and infection of an MDRO.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident with limited mobility receives appropriate services and equipment to maintain or improve mobility with the maximum practicable independence unless a reduction in mobility is unavoidable for 1 of 1 Resident (Resident #1) whose records were reviewed for motorized wheelchairs. The facility failed to obtain Resident #1's motorized wheelchair's specifications, to assess and ensure Resident #1 had a wheelchair that met his weight capacity for at least 3 months. This violation could place residents at risk of utilizing an unsuitable motorized wheelchair and contribute to unsafe mobility.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure:each resident received adequate supervision and assistive devices to prevent accidents for 1 of 2 Residents (Resident #2) whose records were reviewed. Nursing staff failed to ensure Resident #2's bed was in the lowest position and staff provided Resident #2 with adequate supervision. This violation could place residents at risk for experiencing avoidable falls.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to establish and maintain an infection control program designed to provide a safe sanitary, and comfortable environment for 6 of 10 residents (Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, Resident #8 and Resident #10) reviewed for infection control. The facility failed to ensure residents who lived on the 300/400 hallway of the facility received showers in a room that was free of potentially infectious debrisThe facility failed to ensure Resident #4, and Resident #6 were screened for tuberculosis prior to or upon admission to the facility and annually. These failures could cause the spread of infections from one resident to another, leading to sickness and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the resident's right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 1 resident (Resident #6) reviewed for accommodations of needs. The facility failed to ensure Resident #6 had the proper Bariatric bed and overhead trapeze to facilitate self-positioning, self-transfer and bed safety. This failure could cause residents to lose independent functioning as related to Activities of Daily Living, loss of dignity, and overall well-being.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure residents had the right to receive visitors of his or her choosing at the time of his or her choosing, subject to the resident's right to deny visitation when applicable, and in a manner that does not impose on the rights of another resident. The facility failed to ensure door access to residents after 8:00PM daily for 1 of 10 residents (Resident #3) reviewed for visitation rights. This failure could lead to reduced communication and contact between residents, families and others, resident isolation and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents had the right to reasonable access to the use of a telephone and a place in the facility where calls can be made without being overheard. The facility failed to protect and facilitate residents' right to communicate with individuals and entities within and external to the facility, including reasonable access to a telephone, for 2 of 10 residents (Resident #4 and Resident #10) reviewed for Resident Rights. Resident #4 had a personal cell phone but was unable to use it due to decline in visual impairment. Resident #10 did not have a personal cell phone and the only means of outside communication was through a facility-provided telephone. These failures could lead to reduced communication and contact between residents, families and others, resident isolation, and decreased quality of life. [...]

Inspectors wroteBased on observations, interviews and record reviews the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 10 residents (Resident #1) reviewed for smoking safety. The facility failed to ensure that a resident did not keep cigarettes and a lighter in their personal possession. This failure could lead to risk of injury, potential fire incidents and a decreased quality of life.

Inspectors wroteBased on observations, interviews and record reviews the facility failed to provide each resident with a nourishing, palatable, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 10 resident (Resident #6) reviewed for Diet Meets the Needs of Each Resident. The facility failed to ensure Resident #6 received the prescribed therapeutic diet. This failure could place residents at risk of their nutritional needs not being met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible for 4 of 7 residents (Resident #23, Resident #9, Resident #37 and Resident #17) reviewed for accidents and hazards: 1. The facility failed to ensure Resident #23 did not have a disposable razor at the bedside.2. The facility failed to ensure Resident #9 did not have a pair of large nail clippers in her room.3. The facility failed to ensure Resident #37 did not have a pair of large nail clippers and a disposable razor in her room.4. The facility failed to ensure Resident #17 did not have a pair of scissors at the bedside. These failures could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 6 of 8 residents (Resident #15, #18, #31, #19, #17 and #9) reviewed for infection control.1. The facility failed to ensure LVN A sanitized the blood pressure cuff when obtaining Resident #15, Resident #18, and Resident #31's blood pressure. 2. The facility failed to ensure LVN A wore gloves when applying a lidocaine patch to Resident #18's lower back. 3. The facility failed to ensure LVN C sanitized the blood pressure cuff when obtaining Resident #19, and Resident #17's blood pressure. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents had the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options for 1 of 6 residents (Resident #39) reviewed for informed consent. The facility failed to ensure a psychotropic medication consent was included in the medical record for Resident #39's Olanzepine (an atypical antipsychotic medication). This failure could place residents at risk of receiving care/treatment without consent and knowledge of adverse side effects.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure 1 of 8 residents (Resident #2) received services in the facility reviewed for reasonable accommodation of resident needs related to call lights. The facility failed to ensure the call light was within reach for Resident #2. This deficient practice could affect any resident and place them at risk of not being able to ask for help as needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 3 resident (Resident #9) reviewed for enteral feeding:The facility failed to ensure Resident #9's feeding formula and water containers were labeled with the appropriate identifiers and did not discard the feeding containers after the feeding was completed. This deficient practice could place residents who received enteral nutrition at risk of infection, and bloating discomfort.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the discharge of Resident #1 was documented in the EMR for one resident (#1) of four residents reviewed for discharge. The facility failed to provide Resident #1 with a 30-day discharge notice when he was sent to the hospital for a change in condition and the facility refused to take him back. Documentation of discharge was not present in Resident #1's EMR to include physician's orders or a discharge summary. This failure could affect residents who go to the hospital for a change in condition and result in an unsafe discharge.

Inspectors wroteBased on interview, and record review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse, to the administrator of the facility and to other officials including to the State Survey Agency where state law provides for jurisdiction in long-term care facilities in accordance with State law through established procedures for 2 of 4 residents (Residents #1 and #2), reviewed for freedom from abuse, neglect, and exploitation. 1. Facility failed to report incident of suspected abuse from Monday 04/12/2025 when Resident #1 stated she had been fondled by man. 2. Facility failed to report an incident of suspected physical abuse from Monday 04/12/2025 when Resident #2 stated he had been hit by a female resident. [...]

Inspectors wroteBased on interviews, and record reviews the facility failed to have evidence all allegations of abuse, neglect or mistreatment were thoroughly investigated and documented for 2 of 4 residents (Resident #1 and Resident #2) reviewed for abuse. 1. The Facility failed to ensure an allegation of Resident #1 being fondled by a man was thoroughly investigated. 2. The Facility failed to ensure an allegation of Resident #2 having been hit by a female resident was thoroughly investigated. These failures could place residents at risk for abuse and neglect by not investigating allegations of abuse, neglect, exploitation, or mistreatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 1 (Resident #1 room) of 4 resident reviewed for resident rights, in that: A pile of yellow liquid was seen on the restroom floor of Resident #1's room. This failure could result in physical and psychosocial harm due to diminished quality of life and increased risk for falls.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 2 medication carts (Medication Cart 2), reviewed for security, in that, An unassigned medication cart was unattended and unlocked with medication blister packs inside of the medication cart. This failure placed residents at risk for harm by misappropriation of property of their medications.

Inspectors wroteBased on interview and record review, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition services for 1 of 1 dietary manager reviewed for qualified dietary staff. The facility failed to employ a certified dietary manager as required. This failure could place residents who consumed food prepared by staff in the kitchen at increased risk of food borne illness and not receiving adequate nutrition.

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 for 1 of 1 kitchen, in that: 1. A plastic bag of cheese in the refrigerator was not labeled or dated. 2. A plastic bag of beets in the refrigerator was not labeled or dated. 3-A one gallon plastic container of pudding was not labeled or dated 4. The temperature gauge on the dish machine in the dish room was not working as the temperature reading would not advance on the gauge. 5. Snacks in the Nourishment Rooms were not labeled or dated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. The facility failed to secure a resident's bathroom ceiling fan, replace a resident's bedroom light, fix a resident's window blinds, repair a penetration in a resident's bedroom wall, replace a hallway ceiling panel cover, repair water discoloration marks around a hallway ceiling vent, fix a section of resident hallway floor molding, and replace the light bulbs in a hallway ceiling light unit. This deficient practice could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on observation and interview, the facility failed to maintain an effective pest control program for 1 of 1 facility in that: 1. Numerous gnats were observed in a resident room on the 200 hall. 2. Numerous flies were observed on the 200 hall. 3. Observed a cockroach in the conference room This deficient practice could place residents at risk of residing in an environment with pests.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 19 residents (Resident #48) reviewed for care plans. The facility failed to develop a care plan to address Resident #48's anti-coagulant medication use. This failure could have placed residents at risk of not having their needs identified and met.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 4 residents (Resident #1) reviewed for adequate supervision in that: The facility failed to ensure Resident #1 received supervision during mealtimes to prevent choking or aspiration. An IJ was identified on 4/12/24. The IJ template was provided to the facility on [DATE] at 6:19 PM. While the IJ was removed on 04/14/24 the facility remained out of compliance at a scope of isolated with a severity of potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of choking, weight loss, decline in health, and death.

Inspectors wroteBased on observation, interview and record review the facility failed to provide housekeeping and maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable interior for 4 of 5 Resident's (Resident #2, Resident #3, Resident #6, and Resident #7) reviewed for environment. 1. The facility failed to prevent Resident #2's bathroom from having a black substance caked over the interior of the toilet bowl and the air conditioning unit was covered in dust. 2. The facility failed to ensure the wall on the back of Resident #3's bed did not have peeling drywall. 3. The facility failed to ensure Resident #6's room floor was cleaned near/under furniture and in the closet. 4. The facility failed to ensure Resident #7's room floor was cleaned. [...]

Inspectors wroteBased on interviews and record reviews, 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 2 of 4 residents (Resident #1 and Resident #5) reviewed for care plans. 1. The facility failed to care plan Resident #1's refusal eating in the dining room for supervision with meals. 2. The facility failed to care plan Resident #5's use or refusal to use fall mats. This failure could place residents at risk of not having their needs met. Finding Included: 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the drugs and biologicals used in the facility must be labeled and stored in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions and the expiration date when applicable for 1 of 4 resident rooms (Resident #4's room) reviewed for medication storage. The facility failed to ensure Resident #4's medications were stored properly in the facility. This deficient practice could affect residents who received medications for treatments and could result in less potent or an adverse effects and drug diversion.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 1 of 3 residents (Residents #1) reviewed for food and nutrition services. The facility failed to ensure Resident #1 received a mechanical soft diet in the proper consistency. This deficient practice could place residents who received pureed meals at risk of dissatisfaction, poor intake, choking, and/or weight loss.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to accommodate residents' food preferences and allergies for 1 of 3 (Resident #1) residents reviewed for food preferences and allergies, in that: The facility failed to ensure that Resident #1's daily dietary form reflected the residents allergy to mushrooms. These failures could cause an allergic reaction, a decrease in resident choices, and diminished interest in meals.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide drinks, including, water and other liquids, consistent with resident needs and preferences for 1 (Resident #1) of 4 Residents observed for meal service. The facility failed to provide water during lunch on 04/10/24 for Resident #1. This failure could place residents at risk for thirst, dehydration, and decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide special eating equipment and utensils for residents who need them and appropriate assistance to ensure that the resident can use the assistive devices when consuming meals for 1 (Resident #1) of 3 residents reviewed for special eating equipment and assistance when consuming meals, in that: The dietary staff failed to provide Resident #1 with a divided plate to meet Resident #1's need for assistance with eating. This failure could place residents at risk for harm by weight loss, diminished independence, and self-esteem.

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 and to restore continence to the extent possible for 1 of 6 residents (Resident #44) reviewed for incontinent care, in that: CNA A failed to separate Resident #44's labia to clean between the labia during incontinent care. This deficient practice could place residents at-risk for infection and skin break down due to improper care practices.

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 infection for 1 of 6 residents (Resident #44) reviewed for infection control, in that: CNA A failed to wash or sanitize his hands or change his gloves after touching the bed's remote and head of the bed and before starting incontinent care. This deficient practice could place residents at-risk for infection due to improper care practices.