Avir at Arden Wood

Inspectors wroteBased on interviews and record reviews the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 1 of 9 residents (Resident #8) reviewed for quality of care. The facility failed to properly notify MD of Resident #8's radiology results reporting a fracture to the resident's leg resulting in a delay in the resident's need for hospital transfer (27-hrs.) after a reported fall. This failure placed residents at risk for injuries, infections, unwanted hospitalization, and amputation leading to a decrease in quality of life. Findings Included:Record review of Resident #8's face sheet reflected the resident was a [AGE] year-old female who admitted to the facility on [DATE] and readmitted on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that resident environment remains as free of accident hazards as is possible for 1 of 9 (Resident #8) resident reviewed for quality of care. The facility failed to safely secure the locking mechanisms on Resident #8's bed wheels on a bed in high position, resulting in resident's fall with injury fracture on 04/09/2026. This failure could place residents at risk of injury or anxiety due to unstable environmental hazard.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the ordering physician, results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner for 1 of 7 residents (Resident #8) reviewed for diagnostic services. The facility failed to ensure LVN K notified the physician/ NP of the Resident #8's femur fracture using the facility's approved notification methods leaving Resident #8 with an undiagnosed/untreated femur (longest bone in th body that extends from the hip to the knee) fracture and in pain documented up to 5 out of 10 for 18 hours before she was transported to the hospital on [DATE]. This failure could place residents who required radiology services at risk for delayed identification and treatment of undiagnosed illnesses, hospitalization, pain, and suffering.

Inspectors wroteBased on observation, interview, and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid for 1 of 12 resident (Resident #4) reviewed for PASRR services. - The facility failed to refer Resident #4 to identify and update Resident #4's PL1 when she had a newly evident mental illness diagnoses of MDD with severe psychotic symptoms on 04/29/21 and Schizophrenia in 09/23/21 until 05/21/26, preventing a PASRR (a screening required that ensures individuals with MI or ID/DD are not inappropriately placed in nursing homes and received required specialized services) evaluation and determination of services needed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments to reflect the current condition for 1 of 8 residents (Resident #4) reviewed for care plan revisions. - The facility failed to ensure Resident #4 care plan was comprehensive and updated to reflect Resident #4's diagnosis of schizophrenia that dated back to 09/13/2021. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide pharmaceutical services to meet the needs of each resident (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals,) for 1 of 1 medical supply reviewed for medication storage and labeling. The facility failed to ensure the medication room was free from expired medical supplies on 05/22/2026. This failure could place residents at risk of using items that were less effective or risky due to a change in their chemical composition (change of a substance into something else, often making it weaker, useless, or harmful), and could cause infections due to compromised sterile equipment.

Inspectors wroteBased on observation , interview, and record review, the facility failed to ensure based on the comprehensive assessment of a resident that a resident received care, consistent with professional standards of practice, to prevent pressure ulcers and did not develop pressure ulcers unless the individual's clinical condition demonstrated that they were unavoidable for 1 of 3 residents (Residents #25) residents reviewed for pressure ulcers. - The facility failed to ensure the pressure redistributing function of Resident #25's air mattress was not interrupted by a fitted sheet on 05/19/26. This failure could place residents at risk of developing, reopening and worsening of pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 25 Residents (Resident #16) reviewed for -pharmacy services. - The facility failed to ensure a tube of numbing medicine, Lidocaine and Prilocaine 2.5%/2.5% was not left unattended on Resident #16's bedside table. This failure could place residents at risk of adverse reactions to medications and misappropriation of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the daily staffing was posted and readily accessible for review for 1 of 1 facility reviewed for required postings. - The facility failed to post the Daily Staffing Posting in a location visible to all by posting it on the wall on the left side of the building at the entrance to the 200 Hall.- The facility failed to include the name of the facility, and the total number of hours worked by direct care per shift on the Daily Staffing Posting on 05/19/26 to 05/22/26. These failures could affect residents, facility visitors, vendors, and emergency personnel by placing them at risk of not having access to information regarding daily nursing staffing in a timely manner. Findings Include: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 3 of 3(Resident #19, Resident #4, and Resident #22) residents reviewed for infection control. The facility failed to have signs to acknowledge EBP for rooms [ROOM NUMBER] needed for PPE. This failure had the potential to result in staff not following appropriate PPE, increasing the risk of transmission of infectious organisms.

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 dietary services, in that: The facility failed to ensure the ice machine was free from personal drink items (bottled water) within the stored ice. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on interview and record review the facility failed to coordinate an assessment with the Preadmission Screening and Resident Review program (PASRR) under Medicaid to the maximum extent practicable to avoid duplicative testing and effort for 1 of 1 residents (Resident #119) reviewed for PASRR services. The facility failed to submit a NFSS request for nursing facility specialized services in the LTC Online Portal for Resident #119's Specialized Pressure-Reducing Support Surface Mattress by a specific deadline of 12/04/2024 This failure could place residents with a positive PASRR evaluation at risk of not receiving specialized PASRR services which could contribute to a decline in physical, mental, psychosocial well-being and quality of life.

Inspectors wroteResident #98 General 03/28/25 01:41 PM resident did not have upper parameter for blood sugar monitoring in MD orders, did call MD for clarification and had high blood sugar for consecutive days.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure medical care of each resident was supervised by a physician and a physician, physician assistant, nurse practitioner, or clinical nurse specialist provided orders for the resident's immediate care and needs for one of seven residents (Resident #98) reviewed for physician services . The facility failed to ensure Resident #98 had an order for blood sugar parameters for when to report blood glucose levels to the physician according to their policy. This failure placed residents at risk for potential lack of medical supervision by a physician.

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 1 of 8 residents (Resident #6) reviewed for pharmacy services. -The facility failed to give Resident #6 medications as ordered by the physician on 3/25/2025. - The facility failed to maintain accurate records of controlled drugs when LVN B signed out a Lorazepam pill but did not administer it. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys for 2 (Station 1 medication cart for the front hall and secured unit medication cart for the back hall) of 3 medication carts reviewed. The narcotic box in the medication cart for the back hall in the secured unit contained a pill card for Lorazepam 0.5 mg with a piece of tape over a torn protective seal. The narcotic box in the medication cart for station 1 front hall contained a pill card for Tramadol 50 mg and a pill card for Lorazepam 1mg with torn protective seals. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for one (Resident #1) of eight residents whose records were reviewed for abuse and neglect. The facility failed to supervise Resident #3 and Resident #2, which ended in an unwitnessed resident to resident altercation. Resident #3 was struck on the head with a trashcan and sustained a laceration and hematoma to the forehead which required a hospital visit. On 02/14/24 at 10:45 am an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/17/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness their Plan of Removal. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs, for two (Resident #2 and #3) of eight residents reviewed for care plans. 1.) The facility failed to update Resident #2's care plan after he demonstrated a history of aggressive behaviors regarding resident care and his personal space to staff and residents. 2.) The facility failed to include that Resident #3 was a fall risk in the care plan. On 02/12/24 at 01:50 pm an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interview and record review the facility failed to review and revise the person-centered care planning for one (Resident #2) of eight residents reviewed for care plan revision. 1. Resident #2's care plan had not been revised to include behavioral triggers and aggression. On 02/12/24 at 01:50 pm an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/15/24, the facility remained out of compliance at a scope of pattern and a severity level of no actual harm with potential for more than minimal harm that was not an Immediate Jeopardy, due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure could place residents at risk for decreased quality of care and quality of life.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 (Resident # 1 and Resident #2) of 5 residents reviewed for environment. -The facility failed to ensure staff had access to memory care Residents #1 and #2, for approximately 50 minutes, in the event of an incident or emergency when their bedroom door became wedged with their bathroom door preventing the bedroom door from opening. On 01/30/24 an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 02/01/24, the facility remained out of compliance at a severity level of potential for more than minimal harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. [...]

Inspectors wroteBased on observation and interview, the facility failed ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 2 residents (Resident #3 and #4) reviewed for activities of daily living. -The facility failed to provide incontinence care timely to Resident #3 and #4. These failures could place residents who were dependent on staff for ADL care at risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #3 and #4) reviewed for urinary incontinence. -CNA G did not practice proper technique while providing incontinent care for Resident # 3. -CNA H did not practice proper technique while providing incontinent care for Resident # 4. This deficient practice could place residents at risk for infection and skin breakdown due to improper care practices.

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 2 residents (Resident #3 and #4) reviewed for infection control. -The facility failed to use proper infection control precautions when providing incontinence care to Resident #3 and #4. These failures could place residents at risk for cross contamination, infections, delay in treatment, and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was free from neglect for 13 of 15 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #49, Resident #51, Resident #61, Resident #84, Resident #100, Resident #107, Resident #109) across 3 out of 3 units (100-Hall, 200-Hall and 300 Hall) reviewed for neglect. - The facility failed to take the appropriate actions of: [...]

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 and follow accepted national standards for 13 out of 15 residents (Resident #1, Resident #16,Resident #20, Resident #25, Resident #37, Resident #39, Resident #51, Resident #61, Resident #81, Resident #84, Resident #95, Resident #100, Resident #107, Resident #109) and 4 of 5 Staff ( CNA AA, CNA BB, CNA CC, CNA D and CNA S) reviewed for infection control. - The facility failed to implement environment controls and surveillance to prevent a scabies outbreak. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure a person designated as the infection preventionist had completed specialized training in infection prevention and control for 1 of 1 staff (DON) reviewed for Infection Preventionist qualifications and role. - The facility failed to ensure the DON had completed the required Nursing Facility Infection Preventionist training course IP which resulted in failure to implement an effective Infection Control Program, resulting in Residents #107, #39, #25, #37, #100, #51, #61, #81, #16, #84, #109, #20, and #1 contracting and being treated for scabies. - The facility failed to ensure the Infection Preventionist completed tracking and trending of infections for August through October of 2023. - The facility failed to ensure that there was a qualified Infection Preventionist from November 4th to December 15th 2023. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 2 Residents (Resident #49) reviewed for tracheostomy care, in that:. -the facility failed to immediately reposition the oxygen mask over Resident #49's tracheostomy when the resident was found in distress. -the facility failed to immediately suction Resident #49's tracheostomy when the resident was found in distress, with copious (abundant) amounts of secretions at the tracheal tube. -the facility failed to ensure the oxygen mask was in place to provide continuous oxygen flow to Resident #49 prior to leaving the resident's room. [...]

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure that licensed nurses possess the specific competencies and skill sets necessary to provide nursing services to meet the residents' needs safely, and in a manner that promotes each resident's rights, physical and mental well-being as identified through resident assessments, and described in the plan of care for one of 16 (LVN R) facility staff reviewed for competencies and skill sets for assessments, in that: LVN R failed to take prompt actions and identify potential issues early, without Surveyor intervention when Resident #49 was observed to be in distress for an unknown period of time. LVN R failed to ensure Resident #49 was receiving continuous oxygen prior to leaving the resident alone. LVN R failed to ensure sterile gloves were used prior to handling the sterile suction catheter for Resident #49. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the 1 of 4 resident's (CR #75), representative of the transfer or discharge and the reasons for the move in writing and send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman, reviewed for discharges, in that: A notice in writing was not issued to CR #75's family member and to the Ombudsman following the facility-initiated discharge on [DATE]. This failure placed residents at risk of a being discharged without notification, their consent and not having their goals met.

Inspectors wroteBased on observation, record review and interviews, 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 1 of 5 residents (Resident#8) and 1 of 3 Med Carts (100 Hall Back Nursing Cart) reviewed for pharmaceutical services. - The facility failed to ensure the 100 Hall Back Nursing Cart did not contain expired Byetta (an injectable drug used to manage blood sugars in residents with type 2 diabetes) for Resident #8. This failure could place residents at risk of not receiving the therapeutic benefit of medications, adverse reactions to medications and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, the expiration date when applicable and stored all drugs and biologicals in locked compartments and under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 out of 4 medication carts (200 Hall Nursing Cart) reviewed for medication storage. - The facility failed to ensure the 200 Hall Front Nursing Cart did not contain inappropriately labeled and in use protein supplements. This failure could place residents at risk of not receiving the therapeutic benefit of medications or adverse reactions to medications. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the facility had effective pest control for one of one kitchens, one of three hallways (Hall 200) and in one of five (Resident #14's room) resident rooms reviewed for pest control, in that: The kitchen was found to have multiple live gnats. The 200 Hall was found to have multiple live gnats. The 200 Hall and Resident #14's room was found to have a live cockroach crawling on the floor. This failure placed residents at risk for the potential spread of infection, cross-contamination, and a decreased quality of life.