Avir at Tierra Este

Inspectors wroteBased interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infection and to restore continence to the extent possible for one of (Resident #1) six residents reviewed for catheter care.- The facility failed to ensure LVN A appropriately monitored and assessed Resident #1 following catheter removal, responded timely to repeated reports of urinary retention, and ensured proper catheter reinsertion resulting in prolonged urinary obstruction, traumatic catheterization, septic shock, hemodynamic instability, and ICU hospitalization.- The facility failed to ensure LVN K removed Resident #1's catheter on 03/20/26 during the day shift when Bladder Training was completed according to physician's orders.- The facility failed to ensure Licensed staff monitored Resident #1's urinary [...]

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 one of four residents (Resident #4) reviewed for Enhanced Barrier Precautions.-The facility failed to implement their policy on Enhanced Barrier Precautions (EBP) for Resident #4 who had indwelling medical devices.-The facility failed to ensure that PPE was readily available for the staff to use when providing direct care to those residents on EBP.This failure 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 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 6 residents (Residents #1) reviewed for medical records.- The facility failed to ensure LVN A documented in Resident #1's electronic clinical record on 3/24/26 when he assessed the resident for urinary retention and signs and symptoms of urinary tract infection throughout the morning shift.- The facility failed to ensure LVN A documented in Resident #1's electronic clinical record on 3/24/26 when he completed the bladder irrigation. These failures place residents at risk of having incomplete and accurate clinical records.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain food service practices under sanitary conditions by not ensuring dietary staff performed proper hand hygiene during food handling and meal service. The facility failed to ensure dietary staff A performed good hand hygiene within the context of food handling and sanitation. This failure could place residents at risk of cross contamination and the potential transmission of infectious organisms.

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 the resident rights that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 5 residents (Resident #1) reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives, interventions and timeframes for how staff will meet Resident #1's needs related to her history and risk for dehydration. This failure could place residents at risk of a decline in health due to no care plan being implemented. [...]

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 quality of life for two (Residents #7, and #9) of eight residents who were reviewed for dignity. The facility failed to provide adequate access to disposable briefs, and wipes for Resident #9. The facility failed to provide mechanical lift nets to their assigned resident within a reasonable timeframe causing the resident to stay in bed for prolonged period of time. The facility failed to promote dignity while dining when staff did not serve Resident #7 lunch almost 15 minutes after their tablemates were served during initial dining room observation on 09/02/25. These is failures could placed the residents at risk of poor self-esteem and decreased self-worth.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide ADL care for 2 (Resident # 94 and Resident #97) of 12 residents reviewed for ADLs. The facility failed to maintain Resident # 94 and Resident #97's fingernails clean and free from debris. This failure could place residents who required assistance with ADL's and resided on secure units of unmet care needs.

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 3 (Residents #5, 29, and 58) of 6 residents reviewed for oxygen use. The facility failed to maintain Resident # 5, 29 and 58's oxygen concentrator filter free from lint and dust on 09/02/2025 This failure could place residents who receive continuous oxygen at risk for not having their air properly filtered. Findings Include: Resident #5 Record Review of Resident # 5's admission Record dated 09/05/25 revealed a [AGE] year-old male with an original admission date of 07/10/2025 and a readmission date of 06/23/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label drugs and biologicals in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 14 residents (Resident #38 and Resident #72) reviewed for pharmacy services. Resident #38 and Resident #72 had an unlabeled clear plastic cup at bed side with Zinc Oxide pomade (skin ointment) and a tongue depressor in it, exposed, and within reach of other residents. This failure could place residents at risk of inaccurate drug administration and not having appropriate therapeutic effects.

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 2 of 6 residents (Residents #1, and #21) reviewed for call lights. The facility failed to ensure resident call lights were within reach for 2 Residents #1, and #21. 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 develop and implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical and nursing needs for one (Resident #13) of six residents reviewed for care plans. The facility failed to have a comprehensive person-centered care plan for Resident #13 to address Resident's urinary indwelling foley catheter. This failure could place residents at risk for unmet care needs, complications with urinary catheter use, and a decline in their overall health and quality of life. Findings Include:Record review of Resident #13's face sheet dated 09/03/25 revealed resident was an [AGE] year-old female with an admission date 06/02/25. Record review of Resident #13's Quarterly MDS dated [DATE] revealed a BIMS score of 1, indicating severe cognitive impairment. [...]

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 (Resident # 51) of 6 reviewed for medication administration. The facility failed to ensure Licensed Staff signed the individual control drug record for Resident #51's after administering controlled medication on 09/02/2025 and 09/03/2025. This failure could place residents at risk for not receiving the intended therapeutic response of prescribed medications and drug diversion of controlled substances.

Inspectors wroteBased on observations, interviews, 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 and transmission of communicable diseases and infections for one (Resident # 63) of fourteen residents observed for infection control in that: Resident #63's catheter drainage collection bag was left on the floor, and the wheel of her side table was on top of the bag. This deficient practice could result in cross contamination, spread of infection and could result in a urinary tract infection.

Inspectors wroteBased on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 DON reviewed for DON coverage. The facility failed to have a full-time DON as of 03/23/25. This failure could place residents at risk of lack or nursing oversight and a higher level of care.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services consistent with professional standards of practice to promote healing and prevent infections for 1 of 2 (Resident #2) residents reviewed for quality of care. The facility failed to ensure Resident #2's wound vac setting was set at 115mmhg as ordered by the physician. This deficient practice could affect residents who receive wound care treatments by placing them at risk for receiving inadequate treatments resulting in the worsening of the wounds.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that 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 4 residents (Resident #4) reviewed for indwelling catheter. The facility failed to ensure Resident #4's indwelling catheter bag was kept from touching the floor. This deficient practice could place residents with indwelling catheters at risk of disease and infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in four of four halls reviewed for environmental conditions. -The facility failed to clean facility over the weekend of 07/28/24 due to not having sufficient personal to clean the resident rooms and common areas. -The facility failed to maintain the environment free of accident hazards. This deficient practice could place residents at risk of not living in a safe, functional, sanitary, and comfortable environment.

Inspectors wroteFACILITY Environment Observation on 07/29/24 at 6:30 AM, revealed tile floors by the entrance of the facility and resident halls were full of dust, dried black stains, and paper particles. There was a white tablet on the floor by the decentralized nurse's station in the 300 Hall. Observation on 07/29/24 at 7:34 AM, revealed there was a white sheet on the floor soaked with water and caution sign directly in front of Janitor's Closet. Observation on 07/29/24 at 8:05 AM, revealed water was leaking from the condensation pipe in the Mechanical Room, the drain was full of water and water was leaking into the hallway and Janitor Room next to the Mechanical Room. Observation on 07/29/24 at 8:05 AM, revealed water was leaking through the floor base into the Janitor room from the Mechanical Room. It was observed the the floor was full of dust and a piece of paper and plastic were on the floor. [...]

Inspectors wroteBased on observation, 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 3 (Resident #6, #296 and Resident #80) of 6 reviewed for pharmacy services. -The facility failed ensure physician order dated 02/24/24 for Resident #6 had a dosage for the Voltaren Gel ordered for shoulder pain. -The facility failed to ensure Med Aide I notified the nurse when Resident #296 refused to take Lactulose on 07/29/24 according to physician's orders. -The facility failed to administer Resident #80 Zinc Sulfate 220 mg on 07/29/24 according to physician's orders. [...]

Inspectors wroteResident #18 Unnecessary Meds, Psychotropic Meds, and Med Regimen Review 07/31/24 02:49 PM Antipsychotic: Order Summary: Aripiprazole Oral Tablet 10 MG (Aripiprazole) Give 1 tablet by mouth at bedtime related to DEPRESSION, UNSPECIFIED (F32. A) Opioid: tramadol HCl Oral Tablet 50 MG (Tramadol HCl) *Controlled Drug* Give 1 tablet by mouth every 4 hours as needed for Pain - Moderate. Antidepressant: trazodone HCl Oral Tablet 50 MG (Trazodone HCl). Give 1 tablet by mouth at bedtime related to INSOMNIA, UNSPECIFIED (G47.00). Wellbutrin XL Oral Tablet Extended Release 24 Hour 150 MG (Bupropion HCl). Give 1 tablet by mouth one time a day for SMOKING CESSATION AID. Diuretics: acetazolamide Oral Tablet 250 MG (Acetazolamide). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 22% based on 12 errors out of 53 opportunities, for two residents (Resident #21, Resident #295) of six residents observed for medication administration, by one (Med Aide E) of four staff reviewed for medication errors. -The facility failed to ensure Med Aide E administered eight morning medications to Resident #21 on 07/29/24. - The facility Med Aide E failed to administer Resident #295 Famotidine 20 mg, Amiodarone HCL 200 mg, Budesonide Inhalation Solution, and Cholestyramine Oral Pkt on 07/29/24 according to physician's orders for the scheduled morning medication pass. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured the accurate acquiring, receiving, dispensing, safe and secure storage of medications for 4 of 4 nurse carts checked for controlled substances; 2 of 2 Med Aide carts checked for storage of medications. -The facility failed to ensure liquid medication stored in medication carts on three halls (200, 300 and 400) did not have dried drippings on the sides of the bottles. -The facility failed to ensure medications were stored according to routes of administration. -The facility failed to ensure 1 of 7 medication carts was locked when not in use. The facility failed to ensure bottle of Betadine stored in the treatment cart was free of dried drippings. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to prepare food by methods that conserve nutritive value in 1 of 1 kitchen reviewed for food preparation. The facility [NAME] N failed to prepare instant mashed potatoes according to manufacturer's serving chart. These failures could could impact the nutritional value of the meal.

Inspectors wroteBased on observations, interviews, and record reviews 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 kitchen sanitation and food storage. -The facility failed to ensure the shelf in the food preparation area used to store spices was free of food particles. -The facility failed to keep food preparation tables and equipment free of white stains, and food particles. -The facility failed to keep the tiles floors free of black grease build-up. - The facility failed to keep food coloring bottle free of dried drippings. The facility failed to keep trash can covered in the food preparation area. -The facility failed to store foods in the refrigerators and freezers in sealed containers. [...]

Inspectors wroteFACILITY Kitchen Observation on 07/29/24 at 6:38 AM during the initial tour in the kitchen revealed: Food Preparation Area: -The shelf directly above the food preparation table by the stove where spice bottles are stored was full of particles food particles. -Stainless steel tables had dried white stains under the steamer and sides of the table -Steamer had white dried stains on the sides -Deep Fryer was full of crumbs and pieces of chicken strips were in the oil -Tile floor between the deep fryer and steamer had dried black stains and there was a piece of chicken on the floor. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain a quality assessment and assurance committee consisting at a minimum the required committee members for 5 of 9 meetings reviewed for QAPI. The facility did not ensure the MD, or a representative attended QAPI meetings. This failure could place residents at risk for quality deficiencies being unidentified, no appropriate plans of action developed and implemented, and no appropriate guidance developed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection prevention and control program, designed to provide a safe, sanitary, and comfortable environment, and to help prevent the development and transmission of communicable diseases and infections, for 1 of 1 treatment car; and 3 of 4 resident halls reviewed for infection control practices. -The facility failed to ensure dirty linen hampers were covered. -The facility failed to ensure opened packages of gauze non-sterile sponges were stored in sealed plastic bags. -The facility failed to store mattress off the floor in storage. -The facility failed ensure facility staff did not store personal belongings in clean linen closet. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that the resident had the right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 12 residents (Resident # 298) reviewed for resident rights, in that: Resident #298's indwelling urinary catheter bag was not covered. The deficient practice could affect residents by contributing to poor self-esteem, and dignity issues.

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 one (Resident #15) of 15 residents reviewed for accommodation of needs. The facility failed to ensure that Resident #15's electronic monitoring camera was not obstructed when care was being provided as requested by the family. This failure could put residents at increased risk of not having their rights/preferences honored.

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 status for 2 (Resident #295 and Resident #6) of 6 residents reviewed for physician notification. -The facility failed to consult with physician and/or Nurse Practitioner when the facility did not have Famotidine 20 mg, Amiodarone HCL 200 mg, Budesonide Inhalation Solution, and Cholestyramine Oral Pkt to administer as ordered on 07/29/24 during the morning medication pass. -The facility failed to consult with physician and/or Nurse Practitioner when the facility did not have a dosage for the Voltaren Gel for Resident #6 ordered 02/24/24. This failure could place residents at risk of delayed medical treatment.

Inspectors wroteResident #15 Privacy 07/29/24 03:19 PM camera [NAME], [NAME], Santa - putting the pillow over the camera - they says it for her privacy- went on administrator . Aracelli DON is telling [NAME] to cover block the cameras. Leave TV and light on during the night - does not know if this is her or the other resident's TV or liResident ght. 7/30/24 - 1:40 PM - COnsurla [NAME] DTEs [NAME] - Moved camera from head of bed to sid [NAME] now cover it Cant give instructions. over the camera. 08/01/24 03:07 PM DON - policies related to cameras - has had concerns about this Homes - reason that they cover if for dignity - want to see Mom - Says to keep an eye on her - Daughters says she is is not sure of the care. Says dignity and privacy concern. question of balance between resident and family rights. [NAME] moves the camera around - hatdit by the lght fixutre but a fire dcncern. [...]

Inspectors wroteBased on interview and record review the facility failed to coordinate assessments with the pre-admission screening and resident review program for one (Resident #50) of 2 residents reviewed for compliance with PASARR regulations. The facility failed to screen Resident #50 for PASARR when she received a new diagnosis of Schizophrenia. This failure could put residents eligible for PASSR services at risk of not receiving PASSR-recommended specialized services.

Inspectors wroteResident #39 General 07/29/24 09:53 AM [NAME], LVN - - wound draining - sent out culture - dressing is not dated - states for hygiene and should be changed - this would be PRN change. - no date. Care Plan - Resident has and LVAD. At risk for complications. Date Initiated: 07/28/2023 Revision on: 08/21/2023 08/01/24 02:20 PM DON - wound care is [NAME] and if she is not avavile and needs to be changes will be done by nursing. Whena wound dressing in schanged it should be dated. shoud be dated so nikno w wound change date and prevent infections. LVAC [NAME] infoemed her - it was soiled. Nurses monitor it as they do their rounds. 3xQ24 hours - condition of dressing should have been caught during rounds. Trigger woudl be how soiled it is - dressing not intact. Risk for infection from the draininge. Tested postive - Was tested in APril, June, negative, last one Monday colledted cam positve. [...]

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 one (Resident #192) of seven residents reviewed for respiratory care and 1 of 1 oxygen storage room observed for oxygen management. -The facility failed to ensure Resident #192 had her nasal cannula on per physicians' orders and that the nasal cannula was covered when not in use. -The facility failed to ensure 4 oxygen metal cylinders were stored in the oxygen storage room. -The facility failed to ensure an oxygen sign was posted outside of the scale room where oxygen was stored. This failure could put the resident at increased risk of receiving insufficient oxygen and of infection. [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure drug regimen irregularities reported by the Pharmacist Consultant were acted upon by the physician for 1 (Resident #21 ) of 6 residents reviewed for physician response to medication regimen review. The facility failed to ensure that the physician responded timely to Pharmacist Consultant recommendations for Resident #21 to evaluate the continued need for iron sulfate beyond 8 weeks of therapy as per CMS Guidelines. These failures could place residents at risk for unnecessary medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for 1 of 3 (Resident #5) residents reviewed for quality of care, in that: The facility failed to maintain communication, coordination, and collaboration with the dialysis facility for Resident #5. This failure could place residents who received dialysis treatments at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure medical records were maintained on each resident that were complete and accurately documented for 3 of 5 (Resident #1, #4 and Resident #2) reviewed for accuracy and completeness of medical records. 1. The facility failed to document the event of Resident #2's allegation of being called stupid and handled rough when ADLs were being performed in the facility progress notes and conduct an incident report. 2. The facility failed to have complete and accurate documentation for a resident to resident altercation between Residents #1 and #4 on 06/23/24. These failures could place residents at risk of not receiving needed service.

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 5 resident rooms reviewed for environment. The facility failed to ensure the broken window in room [ROOM NUMBER] was fixed. This failure could place residents at risk of living in an unsafe environment which may create a potential for a cut, insect bites, or respiratory problems.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies that prohibit and prevent abuse for 1 of 9 employees (the Administrator) reviewed for criminal back ground checks. The facility failed to run the Administrator's criminal background check prior to her starting her duties on 12/04/23. This failure could place residents at risk of potential abuse. The facility completed the following corrective actions to address the non-compliance after the incident occurred but prior to the surveyor entering:

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse were reported immediately, but no later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or no later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury to other officials (including State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with state law for 2 of 7 residents (Resident #1 and Resident #4 ) reviewed for abuse. The facility failed to report resident to resident altercation to HHSC involving Resident 31 and Resident #4. This failure could place residents at risk of continued abuse.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide the necessary treatment and services based on the comprehensive assessment and consistent with professional standards of practice for 1 (Resident #3) of 7 resident reviewed for quality of care. The facility failed to date/initial Resident #3's dressings after treatment was done. This deficient practice could place residents at risk for worsening venous injuries, pain, and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to ensure the facility assessments were documented and facility-wide assessments determined what resources were necessary to care for residents competently during both day-today operations and emergencies for 1 of 1 facility reviewed for facility assessment. The facility failed to ensure the assessment contained information about the level of staff needed to meet each resident's needs. This failure could place residents at risk of inadequate care of treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for professional standards for food service safety. -On 02/09/2024 at 11:51 a.m., [NAME] L and [NAME] M had beards and were not wearing beard nets while preparing food in the kitchen. This failure could affect residents by placing them at risk of food borne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to assure that one (Resident #10) of five residents reviewed for enteral feeding, received appropriate treatment and services to prevent complications of enteral feeding. -The facility failed to ensure that Resident #10's feeding tube bags were labeled with name of resident, date, and time the administration began to ensure residents maintain nutritional status within optimal parameters. This failure could place residents receiving enteral feedings at risk of not being provided the correct enteral feeding and not receiving feeding care in a timely manner to prevent complications.

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 (Residents #12) of 10 residents reviewed for infection control. - The facility failed to ensure staff followed infection control practices of washing hands after glove use during patient care. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 2 (Resident #3 and Resident #4) of 6 residents reviewed for repositioning. The facility failed to ensure Resident #3 and Resident #4 were repositioned every 2 hours. This failure could affect others by placing them at risk of potential medical complications related to changes in condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of needs for 2 (Residents #9 and #16) of 12 residents reviewed for reviewed for call light button placement.: -The facility failed to ensure that Residents #9's and #16's call lights were within their reach. This failure could place residents at risk of not being able to have their needs met.

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 resident (Residents #14) of 12 residents reviewed for infection control. - The facility failed to ensure staff followed infection control practices of washing hands after glove use after assisting a resident with toileting. 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 implement a comprehensive person-centered care plan that includes 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: CNA B failed to follow Resident #1's comprehensive person-centered care plan to use a hoyer lift when transferring Resident #1 and instead used a one-person transfer (Get the surface the patient is moving to and the surface the patient is moving from as close as you can while still leaving enough room for the two of you to move freely). [...]

Inspectors wroteBased on interview and record reviews the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of 4 residents reviewed for accidents. The facility failed to ensure CNA B used the hoyer lift to transfer Resident #1 knowing Resident #1 required the use of a hoyer lift for transfers, instead using the one person transfer technique (Get the surface the patient is moving to and the surface the patient is moving from as close as you can while still leaving enough room for the two of you to move freely) to prevent injury. This was determined to be past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the investigation. [...]

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 residents (Resident #4) reviewed for infection control in that: There was no sign posted outside of Resident #4's room indicating the resident was in isolation. There was no physician orders for Resident #4 being in isolation. These deficient practices could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on the observation, interview and record review the facility failed to ensure the resident environment remained free of accidents hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 2 residents (Resident #2) and 1 of 5 hallways (hall #1) reviewed for accidents and supervision. 1. The facility failed to ensure CNA C used a gait belt when transferring Resident #2, which resulted in a resident fall. 2. Housekeeper E failed to place a wet floor sign after mopping a hallway in the front entrance. These failures could place residents at risk of falls.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 2 of 6 residents (Resident #1 and Resident #5) reviewed for accuracy and completeness of medical records. 1. The facility failed to completely and accurately document neurological checks for Resident #1 after an unwitnessed fall. 2. The facility failed to ensure Resident #5's peer to peer incident was documented. These failures could place residents at risk of not receiving needed services.

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 infections for 2 of 6 closets (Clean Linen Closet and Soiled Linen Closet) reviewed for infection control. The facility failed to ensure one clean linen closet and one soiled closest door remained closed to prevent facility residents from going inside. This deficient practice could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review the facility failed to ensure based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents choices for 1 of 2 residents (Resident #1) reviewed for neurological checks. The facility failed to ensure Resident #1 who had a fall received neuro-checks (a physical examination to identify signs of disorders affecting your brain, spinal cord and nerves [nervous system]). This failure could place residents at risk of potential medical complications related to changes in condition.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 2 residents (Resident #4) observed for respiratory therapy. The facility failed to ensure Resident #4 did not have an empty oxygen tank. This failure could place residents at risk of receiving incorrect or inadequate oxygen support and decline in health.

Inspectors wroteBased on interview and record review the facility failed to ensure the facility assessments were documented and facility-wide assessments determined what resources were necessary to care for residents competently during both day-to-day operations and emergencies for 1 of 1 facility (Facility) reviewed for facility assessment. The facility failed to ensure the facility assessment contained information regarding the level of staff needed to meet the needs of each resident. This failure could place residents at risk of inadequate care of treatment.

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 __5___ halls reviewed for environment. The facility failed to ensure wet floor signs were posted when the facility floor was mopped. This failure could place residents at risk of living in an unsafe environment which may create a potential for a fall.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure to ensure residents the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 resident (Residents #2) out of 5 residents reviewed for accommodation of needs. The facility failed to ensure Residents #2 call light was placed within reach. This failure could put residents at risk of not being able to have their needs met. Findings Include: Record review of Resident #2's face sheet dated 08/17/23, documented she was a [AGE] year-old female admitted to the facility on [DATE]. Record review of Resident #2's History and Physical dated 08/10/23 documented a [AGE] year-old female history of Alzheimer's dementia, with history of multiple falls and unsteady gait. [...]

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. The baseline care plan must be developed within 48 hours of a resident's admission for 1(Resident #1) of 5 residents reviewed for baseline care plan. Resident #1 did not have a baseline care plan that addressed her Respiratory infection. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #1) of 5 residents reviewed for infection prevention and control. The facility failed to ensure direct care staff used proper PPE when providing care for Residents #1 who had COVID-19. This failure could place other residents at risk of exposure to cross contamination of Covid-19.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide 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 3 (Resident #51, Resident #52, Resident #53) of 3 residents reviewed for activities. The facility failed to provide morning activities for Resident #54, #55, and #56. This failure placed the residents at risk of boredom, loneliness, social isolation, and decline in quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections for 1 (Resident #53) of 2 residents reviewed for indwelling catheter. The facility failed to ensure Resident #53 indwelling catheter strap was properly secured on her leg and failed to ensure indwelling catheter was hanging below the bladder preventing urine backflow. These deficient practices could affect residents with indwelling catheters at risk of disease and infections.

Inspectors wroteBased on observation and interview the facility failed to ensure that the daily nurse staffing was posted as required. The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.

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 residents. 1. Food temperature was not recorded for dinner on 5/18/23. This failure could affect residents by placing them at risk of food borne illness.