Avir at Winnsboro

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 1 of 7 (the park place hall) medication carts reviewed for storage of medications. The facility failed to ensure LVN A locked and secured the park place hall medication cart while not in use and unattended on 06/25/26. This failure could place residents at risk for misuse of medication, overdose, drug diversions, adverse reactions of medications, and not receiving the therapeutic benefit of medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 21 residents (Resident #170) reviewed for supervision. The facility failed to ensure Resident #170 eloped (via foot) from the facility to a local energy service company (0.7 miles) on the night of 06/13/25 at 7:45 PM. Resident was found 4 1/2 hours later at 12:24 am on 6/14/25. The noncompliance was identified as PNC. The IJ began on 6/13/25 and ended on 6/14/25. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation.1. The facility failed to ensure the pulled pork was properly thawed before cooking.2. The facility failed to ensure the peas, sweet potato fries, cinnamon rolls, and an unknown type of breaded meat were dated and labeled.3. The facility failed to ensure the baking trays were properly stored and not stored in an office between boxes. These deficient practices could place residents at risk for food borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident was provided and received food and drink that was palatable, attractive, and at a safe and appetizing temperature for 1 of 1 kitchen reviewed for palatable food. 1. The facility failed to provide meal services in a manner to ensure palatable food served was appetizing to residents.2. The facility failed to provide palatable food served at an appetizing temperature or taste to Residents #60, #66, #58, and other anonymous complaints made during the resident council meeting who complained the food served did not taste good. These failures could place residents at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 1 of 5 (Resident #53) residents reviewed. The facility failed to care plan Resident #53's JP, also called a Jackson Pratt drain (a surgical suction drain that gently draws fluid from a wound to help you recover after surgery). This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents requiring respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 residents reviewed for respiratory care (Residents #1). The facility failed to ensure Resident #1's oxygen filter was in the back of the concentrator. This failure could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory disease. Findings Included:Findings Included:Record review of Resident #1's face sheet dated 06/25/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses heart failure, personal history of COVID, altered mental status, anxiety, and high blood pressure. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (Resident #15) reviewed for trauma-informed care. The facility did not ensure Resident #15's care plan had specific triggers for his diagnosis of PTSD, also known as post-traumatic stress disorder (a disorder in which a person has difficulty recovering after experiencing or witnessing a terrifying event). Resident #15 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBASED on interview and record review, the facility failed to ensure the drug regimen was free from unnecessary drugs for 1 of 21 residents reviewed for medications. (Resident #30)The facility failed to ensure Resident #30's Remeron (mirtazapine) (antidepressant medication) was decreased on 04/10/25 when the medical director signed the pharmacy recommendation and agreed to decrease the Remeron (mirtazapine) from 22.5mg to 15mg every night. This failure could place residents who received antipsychotic medications at risk of receiving unnecessary medication.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 6.9%, based on 2 errors out of 29 opportunities, which involved 2 of 6 residents (Resident #66 and Resident #1) reviewed for medication administration. The facility failed to ensure LVN P administered Resident #66's medication of Omeprazole (a medication used to treat conditions involving excessive stomach acid production) correctly on 06-24-25. The facility failed to ensure LVN Q administered Resident #1's medication of fluticasone (a corticosteroid used to treat a variety of inflammatory conditions, primarily those related to allergies and asthma) correctly on 06-24-25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed 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 21 residents reviewed in sample (Resident #1). The facility failed to ensure Resident #1 did not have hibliclens antiseptic skin cleanser (skin cleanser usually used in surgery to prevent skin infections) in her bathroom on the shelf. These failures could place residents at risk of injury. Record review of Resident #1's face sheet dated 06/25/25 indicated she was a [AGE] year-old female who re-admitted to the facility on [DATE] with the diagnoses heart failure, personal history of COVID, altered mental status, anxiety, and high blood pressure. [...]

Inspectors wroteBased on interview and record review the facility failed to conduct and document a facility wide assessment to determine what resources were necessary to care for it's residents competently during both day-to-day operation, including nights and weekend, and emergencies for 1 of 1 facility assessment reviewed for administration and 1 resident who received dialysis (Resident #53). The facility failed to ensure the assessment accurately reflected dialysis patients. This deficient practice could place residents at risk for inadequate care or treatmentsThe

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible and provide supervision to prevent avoidable accidents for 1 of 2 residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 was adequately supervised which resulted in Resident #1 leaving the facility on 08/12/24, walking approximately 0.5 miles , and crossing a busy 2 lane road. The facility failed to ensure the ADON put measures in place to keep Resident #1 from leaving the facility when she said she saw Resident #1 climb the fence. The facility failed to monitor and put measures in place to keep Resident #1, who was high risk for elopement, from eloping after voicing wanting to go home. The noncompliance was identified as PNC. The IJ began on 08/12/24 and ended on 08/14/24. [...]

Inspectors wroteBased on interviews, and record review the facility failed to ensure residents were free from abuse for 2 of 6 residents (Resident #5 and Resident #2) reviewed for resident abuse. 1. The facility did not ensure Resident #5 was free from abuse when Resident #6 attempted to choke and struck Resident #5 on the middle of his back on 12/25/24. 2. The facility did not ensure Resident #2 was free from abuse when Resident #3 slapped Resident #2 on his left upper arm on 12/20/24. The noncompliance was identified as PNC. The noncompliance began on 12/20/24 and ended on 12/26/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk of abuse, physical harm, mental anguish, and emotional distress.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for 1 of 6 residents reviewed for misappropriation of resident property. (Resident #4) The failed to ensure CNA/Van Driver K did not take Resident #4's debit/credit card and use it for her personal use. The noncompliance was identified as PNC. The noncompliance began on 08/12/24 and ended on 08/12/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, misappropriation of property, misappropriation of physician ordered medications and dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consider the views of a resident group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life and failed to demonstrate their response and rationale for such response 3 of 3 groups. There was no documentation of the facility's effort to resolve grievances concerning beds not being made daily and cold food collected at Resident Council meetings on 2/29/2024, 3/27/2024, and 4/18/2024. This failure placed residents at risk of not having grievances addressed or provided a rational for facility decisions for issues identified

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents received mail delivered to the facility for 5 of 5 confidential residents reviewed for right to communication The facility failed to ensure residents received their mail on the weekend. This failure could affect residents in the facility who receive mail at risk for not receiving mail in a timely manner that could result in a decline in resident's psychosocial well-being and quality of life.

Inspectors wroteBased on record review and interview, the facility failed to ensure residents had the right to formulate an advanced directive for 1 of 22 residents (Resident #10) reviewed for advance directives. The facility failed to accurately update Resident #10's comprehensive care plan with her code status. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, psychosocial outcome and inaccurate medical records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 9 residents (Resident #9's) and 1 of 1 dining rooms reviewed for a homelike environment. The facility failed to ensure Resident #9's bathroom was free of offensive odors and unbroken and misshaped tiles around the base of the toilet. The facility failed to ensure the dining room did not have plastic, folding tables used as dining tables. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, for 4 of 6 (Resident #40, Resident #33, Resident #4 and Resident #23) residents reviewed for the care plan. 1. The facility failed to care plan Resident #40 needs to be in the secure unit 2. The facility failed to care plan or write an order for Resident #33's to be in the secure unit. The facility failed to care plan Resident #33 was a smoker. 3. The facility failed to ensure Resident #4's comprehensive care plan addressed she received a prophylactic antibiotic. 4. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 3 of 6 residents (Resident #38, Resident #12, and Resident #33, ) reviewed for accidents and hazards. 1. The facility failed to ensure the fall mat was in place for Resident #38. 2. The facility failed to ensure Resident #12 and Resident #33 had a smoking assessment done monthly per facility policy. These failures could place residents at risk for injury.

Inspectors wroteBased on observation, interview and record review, 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 4 of 8 residents (Residents #11, #54, #50, and #55) reviewed for pharmacy services. 1. The facility failed to ensure MA K administered Resident #11's Clindamycin (antibiotic), Eliquis (anticoagulant), Keppra (antiseizure), and Vimpat (antiseizure) timely as ordered at 8:30 a.m. 2. The facility failed to ensure MA K administered Resident #54's Tylenol (pain medication), Coreg (blood pressure), Gabapentin (used to treat pain), and Isosorbide (blood pressure) timely as ordered at 8:30 a.m. 3. The facility failed to ensure MA K administered Resident #50's Tylenol (pain reliever), timely as ordered at 8:30 a.m. 4. [...]

Inspectors wroteBased on interviews and record reviewss, the facility failed to ensure residents who used psychotropic drugs were not given those drugs unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 of 5 residents (Resident #62) reviewed for unnecessary psychotropic drugs. The facility failed to follow the pharmacy recommendation to discontinue Resident #62's Seroquel/quetiapine (antipsychotic medication) on 04/25/24 therefore Resident #62 received 13 more doses of Seroquel. This failure could place residents at risk for adverse consequences such as impairment or decline in an individual's mental or physical condition or functional or psychosocial status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 38% based on 16 errors out of 42 opportunities, which involved 4 of 8 residents (Residents #11, #54, #50, and # 55) reviewed for pharmacy services. The facility failed to ensure Residents 11, 54, 50, and 55 medications were administered during the scheduled time. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 7 of 7 confidential residents reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and appetizing temperature on 5/08/2024 for confidential residents. These failures could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on interview and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 22 residents (Resident #10) reviewed for resident records. The facility failed to accurately update Resident #10's comprehensive care plan with her code status. This failure could affect residents of the facility by not addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, psychosocial outcome and inaccurate medical records.

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 2 of 22 residents (Resident #14, Resident #17) and laundry services reviewed for infection control practices. 1. The facility failed to ensure Resident #14's catheter bag was not touching the floor. 2. The failed to ensure CNA H wiped correctly and performed hand hygiene while providing incontinent care for Resident #17. 3. The facility failed to ensure laundry staff handled infectious laundry using the appropriate PPE. 4. The facility failed to ensure soiled laundry was transported to prevent the spread of infection. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 of 22 residents reviewed for dignity. (Residents #14 and #36). The facility did not ensure Resident #14's catheter drainage bag was covered for one day. The facility failed to ensure CNA C did not feed Resident #36 while standing. These failures could place residents at risk of a diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 1 of 22 residents (Residents #4) reviewed for reasonable accommodations. The facility failed to ensure Resident #4's call light was accessible. This failure could place residents at risk of injuries, health complications and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to notify the resident's representative immediately when there was an accident or significant change in the resident's physical, mental, or psychosocial status that is, a deterioration of health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 2 of 9 residents (Resident #9 and Resident #39) reviewed for notification of changes. The facility failed to notify Resident #9's representative when Resident #9 sustained a fall on 02/18/2024. The facility failed to notify Resident #39's representative when Resident #39 sustained a fall on 03/31/2024. This failure placed residents' at risk of not having their representative being aware of any changes in their conditions and could result in delay in treatment and decline in residents' health and well-being.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure resident rights of confidentiality of medical records for 2 of 23 residents (Resident #'s 1 and 35) reviewed for medical record confidentiality. The facility failed to ensure MA E closed the EMR of Resident #'s 1 and 35's medication regimen prior to her walking away from the medication cart during the passing of medications. This failure could place residents at risk of their medical information being provided to unauthorized personnel, other residents, or visitors.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. The facility failed to follow their policy on abuse for 2 of 22 residents (Resident #'s 10 and 36) reviewed for abuse. The facility failed to report Resident #10's injury of unknown to HHSC when bruising was found to her perineum. The facility failed to report Resident #36's injury of unknown to HHSC when bruising was found to his bilateral buttocks and left chest. These failures could place residents at risk of being abused and neglected.

Inspectors wroteBased on interviews 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 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did not result in serious bodily injury, to the administrator of the facility and to other officials (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 2 of 22 resident (Residents #'s 10 and 36) reviewed for abuse. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure assessments accurately reflected the resident status for 1 of 22 residents (Resident #41) reviewed for MDS assessment accuracy. The facility inaccurately coded Resident #41 as having had a weight loss on his quarterly MDS assessment dated [DATE]. This failure could place residents at risk for not receiving care and services to meet their needs.

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 for 1 of 6 (Resident #44) residents reviewed for quality of care. The facility failed to ensure Resident #44's diabetic wound was being monitored for improvement or worsening. This failure could place residents at risk of complications which include worsening of existing wounds, development of new wounds, and infection.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 22 residents (Resident #23) reviewed for quality of care. The facility did not ensure Resident #23's trauma screening was completed upon admission to the facility. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview, and record, the facility failed to ensure drugs and biologicals used in the facility were stored and secured properly for 1 of 1 medication storage refrigerators, and 1 of 6 medication carts (Zone 7 medication cart) 1. The facility failed to provide a separately locked, permanently affixed compartment for storage of controlled drugs in the refrigerator of the medication room. 2. The facility failed to ensure MA E locked her medication cart and secure the keys to the medication cart during medication pass. These failures could place residents at risk for a drug diversion of their medications.

Inspectors wroteBased on interview and record review, the facility failed to have a policy identifying those cirumstances when the loss or damage of dentures was the facility's responsibility and failed to provide or obtain dental services to meet the needs of each resident for 1 of 9 (Resident #30) residents reviewed for dental services. The facility failed to provide dental services when Resident #30 lost his dentures. The facility failed to have policies and procedures for lost dentures. 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 store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen. 1. The facility failed to ensure 3 sheet pans were free from a brown colored grease like build up on the inside corners of the sheet pans. 2. The facility failed to ensure 2 cast iron skillets were free from a carbon build up not covering the inside walls and the outside of the skillet. 3. The facility failed to ensure the juice machine was free from dusty like material on the front and sides. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure the quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 2 of 3 residents (Resident #40 and Resident # 18) reviewed for hospice services. The facility failed to maintain Resident #40's hospice binder containing information related to hospice services provided for the resident. The facility failed to obtain Resident #18's most recent hospice plan of care. [...]

Inspectors wroteBased on interview and record review, the facility failed to promote antibiotic stewardship by ensuring the appropriate use of antibiotic therapy and providing written rationale, by the provider, when an antibiotic Zithromax was used despite criteria, to determine the appropriate use of an antibiotic for 1 of 6 residents (Residents #44) reviewed for antibiotic use. The facility failed to ensure Resident #44 had documented signs and symptoms and diagnosis to support the use of prescribed antibiotic Zithromax. This failure could place residents receiving antibiotics at risk for unnecessary antibiotic use, inappropriate antibiotic use, and increased antibiotic-resistant infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the resident environment remained free of accident and hazards for 2 of 7 residents (Residents #1 and #2) reviewed for accident hazards. CNA B and CNA C failed to ensure Resident #2's Hoyer lift (an assistive lift device that allows for transfer using electrical power) transfer was performed correctly. CNA D did not lock Resident #1's bed during incontinent care. These failures could place dependent residents at risk for falls, significant injuries and decreased quality of life.

Inspectors wroteBased interview and record review the facility failed to immediately inform the resident's responsible party when there was a significant change in the resident's physical, mental or psychological status for one resident (Resident #41) reviewed for notification of change of condition, in that: The facility failed to notify Resident #41's responsible party when Resident #41 sustained a fractured finger after an incident where Resident #41 had another resident sit in a chair and caught Resident #41's finger in between chairs. This failure placed residents' caregivers at risk of not being aware of any changes in their conditions and could result in a delay in treatment and decline in residents' health and well-being.

Inspectors wroteBased on interview and record review, the facility failed to 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 4 of 8 residents (Resident #31, Resident # 32, Resident #33, and Resident #41) reviewed for comprehensive person-centered care plans. 1. The facility failed to include Resident #31's behavior to take others food and drinks in her care plan after she was involved in a resident-to-resident altercation for taking another resident's milk on 06/26/2023. 2. The facility failed to care plan Resident #32's and Resident #33's risk for resident-to-resident altercations after an altercation that occurred between them on 07/19/2023. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 4 of 4 residents (Residents #34, Resident #35, Resident #36, and Resident #37) reviewed for pharmacy services. 1. The facility failed to ensure MA C (no longer employed) documented on Resident #36's narcotic record the time of administration for 1 dose of hydrocodone-acetaminophen (a narcotic medication used for pain) given on 06/16/2023. 2. The facility failed to ensure MA B documented on Resident #37's narcotic record the time of administration for 1 dose of hydrocodone-acetaminophen given on 10/17/2023. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to, in accordance with accepted professional standards and practices, maintain clinical records on each resident that were complete and accurately documented for 1 of 15 residents (Resident #42) reviewed for clinical records. The facility failed to ensure Resident #42's electronic record reflected the residents accurate skin conditions during her respite stay from 10/04/23-10/08/23. This failure could place residents at risk of worsening skin integrity and decline in comfort level.

Inspectors wroteBased on observations, and interviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public in 3 of 3 showers (Whispering Lane shower, Park Place shower, and Texas Boulevard shower), and 1 of 3 public restrooms (nursing station area public restroom) observed. 1. The facility failed to ensure the three common shower rooms were free of black and green substances growing in the grout, towels lying on the floor, and a pink slimy substance growing on the undersurface of the shower chairs. 2. The facility failed to ensure the bathtub in the public restroom was free of a black substance . These failures could place residents at risk of infections and a loss of dignity.

Inspectors wroteBased on observation, interview and record review 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 1 of 1 resident (Resident #12) reviewed for activities of daily living. The facility failed to remove Resident #12's facial hair. This failure could place residents at risk of embarrassment, decreased self-esteem, or decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents environment remained free of accident hazards for 1 of 2 resident (Resident #5) reviewed for transfers. The facility failed to ensure Resident #5 was transferred using a gait belt. This failure could place residents at risk for injuries and falls.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that medication error rates of 5 percent or greater. The facility had a medication error rate of 7.14 %, based on 2 errors out of 28 opportunities, which involved 1 of 7 residents (Resident #23) reviewed for medication administration . The facility failed to ensure Resident #23 received aspirin (non-steroidal anti-inflammatory) and magnesium oxide (supplement) at the correct dosage. This failure could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, ensure 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 1 of 6 medication carts (main street medication cart) reviewed for medication storage. The facility failed to ensure the main street hall medication cart was locked when the ADON left the floor and left the cart unattended. This failure could place residents at risk of taking medications not intended for them with adverse outcomes; risk of loss/interruption in receiving medications.

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 2 of 16 residents (Residents #5 and #23) reviewed for infection control practices. 1. CNA A failed to wash or sanitize her hands before, in between glove changes, and after performing peri care to Resident #5. 2. The facility failed to ensure the ADON used gloves when she administered Resident #23's eye medication. 3. The facility failed to ensure the ADON did not dry Resident #23's eyes with the same tissue used to clean Resident #23's nose. These failures could place residents at risk for infections.