Avina on 32nd

Inspectors wroteBased on interview and record review, the facility did not employ sufficient staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition services. Dietary Manager (DM)-G did not have a qualified certificate to manage the kitchen. This deficient practice had the ability to affect all 50 residents who receive meals from the kitchen.

Inspectors wroteBased on interview and record review, the facility did not ensure accurate mandatory submission of staffing information based on payroll data in a uniform electronic format to the Centers of Medicare and Medicaid Services (CMS). Staffing information for Fiscal Year Quarter 2 2026 (January 1, 2026 - March 31, 2026) of the Payroll Based Journal (PBJ) was not accurately submitted to CMS.This deficient practice has the potential to affect all 51 residents residing in the facility.

Inspectors wroteBased on record review and interview, the facility did not implement written policies and procedures that prohibit and prevent abuse, neglect, and exploitation of residents and misappropriation of resident property. The facility did not conduct a background information disclosure (BID) every four years for certified nursing assistant (CNA)-M or CNA-V.This has the potential to affect residents who may receive care from CNA-M or CNA-V.

Inspectors wroteBased on interviews and record review the facility did not ensure residents are free from unnecessary psychotropic or antipsychotic medications for 2 (R3 and R9) of 5 sampled residents. R3 had orders to decrease Abilify (Aripiprazole) which was incorrectly transcribed, resulting in an increase of the medication. Specific behaviors explaining the need for the medication and to justify the increase in the medication were not identified and documented. R9 had orders for Quetiapine Fumarate (Seroquel) scheduled at bedtime and every 12 hours PRN (as needed) upon admission to the facility. The scheduled dose was increased twice within 2 months with no evidence of behaviors to justify the increase in dosage and the PRN order extended beyond 14 days. In addition, Haloperidol PRN was ordered and extended beyond 14 days. There was no evidence of behaviors to justify use of the medication.

Inspectors wroteBased on interviews and record review, the facility did not ensure 3 (R34, R4, and R46) of 5 residents with an allegation of abuse or involved in a resident-to-resident altercation were reported to the State Survey Agency within the required reporting timeframe. *R34 informed facility staff that Certified Nursing Assistant, (CNA)-Y, was rough with cares. This allegation of abuse was not reported to the State Survey Agency. *A resident-to-resident altercation involving R4 and R46 was not reported to the State Survey Agency within the required reporting timeframe.

Inspectors wroteBased on interviews and record review, the facility did not ensure an allegation of abuse and a resident-to-resident altercation was thoroughly investigated for 1 (R34) of 5 sampled residents reviewed for allegations of abuse.*R34 informed facility staff that Certified Nursing Assistant, (CNA)-Y, was rough with cares. This allegation of abuse was not thoroughly investigated.

Inspectors wroteBased on observation, interview and record review the facility did not ensure that residents received proper foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assisting the resident in making necessary appointments with qualified healthcare providers such as podiatrists for 1 of 1 (R34) residents reviewed for foot care.*Facility staff found that R34 had an ingrown toenail in August of 2026. R34 developed multiple infections due to the ingrown toenail. R34's Wound MD-W, R34's Nurse Practitioner (NP)-X and emergency room physicians all recommended that R34 be referred to a podiatrist for care and treatment. Facility staff did not always follow the doctor's recommendations for treatment and did not provide podiatry services until February 2026. [...]

Inspectors wroteBased on observation, interview and record review, the facility did not comprehensively assess a resident after applying bed mobility devices for 1 of 1 sampled residents' (R7) reviewed for mobility devices.*R7 was assessed to have bed rails to aid in positioning. R7's use of bed rails was not included in R7's care plan. R7 did not have a physician order for the bed rails and R7 was not assessed quarterly for the continued need for the bed rails.

Inspectors wroteBased on interview and record review, the facility did not ensure nurse staffing information included the actual hours worked by registered nurses, licensed practical nurse, or certified nurse aides. Review of weekend staffing schedules and required staff postings from 1/1/26 through 1/31/26 revealed 6 of 9 days had discrepancies between the documents. This resulted in inaccuracies with the actual hours worked for licensed and non-licensed staff directly responsible for resident care each shift. This deficient practice has potential to affect all 51 residents at the facility.

Inspectors wroteBased on observations, record review, and interviews, the facility failed to support the residents' right to voice a grievance or complaint without discrimination or reprisal. The failure created the potential for residents not to file a grievance or complaint as there were no means to do so anonymously or without staff knowledge. This had the potential to affect a pattern of 54 residents who resided at the facility (R8, R9, R10, R11).

Inspectors wroteBased on observations, record review, and interviews, the facility failed to ensure one of 12 sampled residents (Resident (R) 8) was free from misappropriation of property. The failure to prevent misappropriation of property created the potential for additional misappropriation to have occurred for other residents.

Inspectors wroteBased on interviews and record review, the facility failed to report an allegation of misappropriation of property for one of 12 sampled residents (Resident (R) 8). The failure to report allegations of misappropriation created the potential for additional misappropriation to have occurred for other residents.

Inspectors wroteBased on record review, interviews, and review of facility policy, the facility failed to ensure 13 residents [(R)4, R16, R17, R18, R19, R20. R21, R22, R23, R24, R25, R26, and R27] out of a census of 43 Resident reviewed for misappropriation was free from abuse in the sample of fifteen residents. This failure had the potential for psychosocial impairment from the loss of resident funds by a staff member.

Inspectors wroteBased on observations, interviews, and record review, the facility did not ensure that 13 of 13 residents reviewed for smoking and/or vaping (R2, R3, R299, R36, R299, R14, R37, R34, R31, R32, R22, R31, R150, R38, R149, R43, and R36) and one resident reviewed for transfers (R199) were provided with an environment that was free of accident hazards and/or provided with appropriate supervision. R2 was allowed to vape (use an electronic cigarette) while using oxygen in her room instead of being restricted to designated smoking areas away from oxygen. In addition, the facility allowed charging of the e-cigarette in the resident's room. R3 is severely cognitively impaired. R3 was allowed to smoke without supervision and was allowed to smoke outside of the designated area. There was no safety equipment in the area where R3 was observed smoking. R299 smokes unsupervised. [...]

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure food was properly labeled and dated as to when they expired, and all expired foods were disposed of in accordance with professional standards for food service safety as required for 51 census residents who received meals from the facility kitchen. These failures had the potential to lead to food-borne illness among all facility residents.

Inspectors wroteBased on observations, interviews, and facility policy review, the facility failed to ensure 6 of 28 resident rooms on 2 of 4 halls had been maintained in a safe and homelike manner.

Inspectors wroteBased on observation, interview, record review, the facility failed to ensure 1 of 1 resident (R3) reviewed for self-administration of medications out of a total sample of 31 had been assessed for self-administration of medications, had a physician's order for the self-administrator, and had care plan interventions identified and implemented related to self-administration of medications. Failure to assess and care plan residents for self-administration of medications increases the potential of medication errors for residents.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that 1 of 1 resident (R100) reviewed for suprapubic catheters was provided with appropriate care. The facility did not have an indication for the catheter and failed to ensure there were physician orders for catheter care. In addition, the facility failed to ensure that R100's care plan included the appropriate type of catheter, and that the catheter had a privacy bag.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that 2 of 4 residents (R42 and R149) reviewed for pain management out of a total sample of 31 received pain medications consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences. R42 rated pain at a 6.5 out of 10 and stated that anything over 4 was unacceptable for them. Nursing staff were alerted to R42's request for pain medication at 3:38 PM. R42 did not receive pain medication until 4:15 PM. During that time, R42 verbalized she had pain, and was observed to be moaning and rocking. R149 was experiencing pain rated at an 8 or 9 out of 10. R149 had requested pain medication and it took nursing staff over an hour to respond with the medication. [...]

Inspectors wroteBased on observation, record review, and interview, the facility did not ensure that staff accurately administered medications for 1 of 31 sampled residents (R9). CMT M (Certified Medication Tech) did not mix compounded insulin for R9 prior to administering it. Failure to do so could result in an inaccurate proportion of short or long acting insulin being given.

Inspectors wroteBased on observations, interview, record review, and facility policy review, the facility failed to complete catheter care, wound care, and/or medication administration in a manner to prevent cross contamination for 2 of 31 sampled residents (R35 and R100) on 4 separate occasions.

Inspectors wroteBased on observation, record review and interview, the facility did not ensure that 1 (R1) out of 3 residents who currently had pressure injuries received the necessary care and treatment to promote the healing of the pressure ulcers. R1 was admitted with an unstageable pressure ulcer to her left thigh and left shin. R1 was also admitted wearing a brace to the lower left leg for the healing of a fracture. The facility did not update R1's plan of care to indicate when the use of the leg brace was to be discontinued. The facility also did not update R1's plan of care to include the use of heel boots to provide pressure relief and did not offer to place the heel boots on after wound treatment was performed.

Inspectors wroteBased on observations, record review and staff interviews, the facility did not ensure that they implemented Enhanced Barrier Precautions (EBP) for 2 (R1 & R2) out of 3 residents requiring EBP as recommended by the Center for Disease Control (CDC) and per the Facility's policy.

Inspectors wroteBased on observation and interview the Facility did not provide a safe, comfortable and homelike environment which had the potential to affect a pattern of Residents who use the shower/bathing room on the 2nd & 5th units. * Wing 5 shower/bathing room has ceiling tiles that have been moved exposing ceiling pipes. In the tub area there are 2 tiles missing for the cove base on the right side and on the left side there is a wall tile missing. * Wing 2 shower/bathing room the toilet seat is loose and the call light in the shower area is not working. * There is a piece of floor tile missing on the floor by the door which leads to the smoking area outside.

Inspectors wroteBased on interview and record review, the facility did not develop and implement an effective discharge planning process for 4 (R9, R10, R11, and R12) of 5 Residents reviewed for discharge plans implemented to effectively transition the Residents to post-facility care. *R9 discharged home on [DATE] and the facility did not make the necessary referrals for home health so that services could be started after discharge and to assist with the transition of moving back into the community. The facility did not set up follow-up with a primary care physician(PCP). R9's discharge summary did not include all the pertinent information from all interdisciplinary team(IDT) , a final summary of R9's; status at the time of discharge and a post-discharge plan of care developed with the participation of the resident and/ or representative. [...]

Inspectors wroteBased on interview and record review, the facility did not provide notice of resident rights and services to prior to or upon admission both orally and in writing for 1 of 5 (R12) Residents reviewed. *R12 was admitted to the facility on [DATE] and admission paperwork including but not limited to consent to treatment was not offered to R12. R12 discharged from the facility on 1/26/24. Findings Include: Surveyor reviewed the Admission/readmission policy and procedure revised 10/03 which documents the following: .Policy: 2. A qualified staff member conducts the admission process involving the Resident and family. 3. Questions by the Resident or family receive immediate attention or are directed to the appropriate resource. [...]

Inspectors wroteBased on record review and staff interview, the facility did not ensure all facility reported incidents involving potential abuse, neglect, and misappropriation of Resident property were thoroughly investigated for 1 (R5) of 2 sampled Residents (R). * R5 reported $500 missing on 11/17/23 and the facility only obtained 3 nursing staff statements from 1 shift. Other departments who would have had access to R5's room were not interviewed. Findings Include: Surveyor reviewed the undated facility's Abuse policy and notes the following applicable to completing a thorough investigation: .Abuse Policy This facility affirms the right of our Residents to be free from abuse, neglect, exploitation, misappropriation of property or mistreatment. This facility therefore prohibits abuse, neglect, exploitation, misappropriation of property, and mistreatment of Residents. [...]

Inspectors wroteBased on observation, interview, and record review the Facility did not ensure 1 (R7) of 1 dependent Residents reviewed received required assistance with their ADL's (activities daily living). R7 did not receive incontinence cares according to his plan of care and did not receive oral care .

Inspectors wroteBased on observation, interviews, and record review, the facility did not ensure 1 of 1 Resident (R1) reviewed for abuse was provided medically related social services to assist R1 in attaining or maintaining their mental and psychosocial health. *On 1/7/24, R1 reported that R2 touched R1 sexually inappropriately. A follow-up trauma assessment and psychological referral was not completed to determine R1's psychosocial status. Findings Include: R1 was admitted to the facility on [DATE] with diagnoses of Anxiety Disorder, Major Depressive Disorder, Obsessive Compulsive Disorder, and Hyperlipidemia. R1 is his own person. On 2/7/24 at 8:21 AM, Surveyor reviewed R1's Quarterly Minimum Data Set(MDS) dated [DATE] which documents R1's Brief Interview for Mental Status(BIMS) score to be 15, indicating R1 is cognitively intact for daily decision making. [...]

Inspectors wroteBased on staff interviews, and record review, the facility did not ensure therapy services were provided in a timely manner for 1 resident (R) (R3) of 1 Resident reviewed for therapy services. *R3 was admitted into the facility on [DATE]. R3 was referred to therapy based on R3's comprehensive care plan along with physician orders dated 12/22/23 for evaluation and treatment and R3 was not evaluated until 12/26/23 for speech (ST), and physical (PT) therapy, and was first evaluated for occupational (OT) therapy on 12/27/23. Findings Include: The facility's Admission/readmission policy and procedure revised 10/03 documents that .therapy orders are communicated to the therapy department. The policy also documents .Information about Resident admission is communicated in a timely manner to the appropriate departments. [...]

Inspectors wroteBased on review of daily staff postings, staffing schedules, and interview, the facility did not use the services of a registered nurse (RN) for at least 8 consecutive hours a day, 7 days a week. * On 8/5/23 and 8/19/23 there was no RN who worked for 8 consecutive hours. This deficient practice has the potential to affect all 57 residents residing in the facility on 8/5/23 and all 62 residents residing in the facility on 8/19/23.

Inspectors wroteBased on observation, record review, and interview, the facility did not maintain an effective pest control program so that the facility is free of pests. During the survey, residents complained of the facility having gnats, which were observed by Surveyors. The facility hired an exterminator in the spring of 2023 however the facility continues to have gnats. This deficient practice has the potential to affect all 50 of 50 residents residing in the facility at the time of the survey.

Inspectors wroteBased on observation and interview, the facility did not ensure a clean, comfortable and homelike environment which had the potential to affect 1 of 7 (R20) resident rooms observed and 18 of 18 residents residing on wing 1. *R20's room was observed to have wall scrapping with plaster gouges and the metal door frame was heavily scrapped. * On 10/24 and 10/25/23, a strong persistent urine odor was noted in the 100 unit hallway which had the potential to affect all 18 residents residing in this unit.

Inspectors wroteBased on record review and interview, the facility did not ensure written notification of Medicare Non-Coverage was signed by the resident and/or the resident's representative acknowledging receipt and understanding of the notification and of their appeal rights for 3 of 3 residents (R101, R1, and R36) reviewed whose Medicare coverage was ending, and had remaining Medicare eligible days and remained residing in the facility.

Inspectors wroteBased on observation, interview, and record review the Facility did not provide respiratory care consistent with professional standards of practice for 1 (R44) of 2 Residents reviewed for respiratory care. * R44 was observed not to have his oxygen administered per order, the oxygen was not signed out as administered and his oxygen tubing was not labeled with the date it was changed. R44 also did not have a care plan for oxygen use.

Inspectors wroteBased on interview and record review the facility did not provide pharmaceutical services, including services that assure the accurate storage, dispensing and administering of all drugs and biological's to meet the needs of residents for 1 (R31) of 3 residents investigated for proper medication administration. *R31 was observed to be left 2 doses of a nebulizer treatment for her to self-administer. R31 was observed also to have an albuterol inhaler in her bedside dresser. R31 did not have an assessment or care plan to self-administer these medications.

Inspectors wroteBased on observations and interview, the facility did not ensure garbage and refuse were properly disposed in the outside garbage storage receptacles. This deficient practice had the potential to affect all 50 Residents residing at the facility during the onsite visit. * Excessive litter was observed in the area surrounding two dumpsters which included, paper, wrappers, a black garbage bag, cigarette boxes, cigarette butts and numerous disposable gloves.