Avir at Azalea Heights

Inspectors wroteBased on observation, interview and record review, the facility failed to provide personal privacy when providing care for 1 of 7 (Resident #1) residents reviewed for privacy. The facility did not ensure CNA A and CNA B pulled the privacy curtain while providing incontinent care on Resident #1 on 4/29/26. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

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 of 2 staff (CNA A) viewed for infection control. The facility failed to ensure CNA A performed hand hygiene between glove changes while providing incontinent care to Resident #1 on 4/29/26. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: During an observation on 4/29/26 at 1:16 p.m. CNA A performed incontinent care with assistance from CNA B on Resident #1. CNA A and CNA B obtained hand sanitizer from dispenser on the wall outside Resident #1's room. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure medications were prepared and administered in a manner that prevented medication errors for 1 of 2 MA medication carts (MA Cart #1) and 1 of 2 licensed nurse medication carts (LN Cart #1) observed for controlled medications storage. LVN B was observed on 12/10/2025 signing the controlled substance count sheets for the end of their shift at the beginning of their shift on LN Cart #1. MA A was observed on 12/10/2025 signing the controlled substance count sheets for the end of their shift at the beginning of their shift on MA Cart #1. These failures created the potential for medication diversion, administration of incorrect medication and compromised resident safety could place residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure assessments accurately reflected the resident's status of 1 of 5 residents (Resident #5) reviewed for accuracy of assessments. The facility failed to ensure 1 admission MDS assessment dated [DATE] and 2 quarterly MDS assessments dated 04/02/25 and 07/03/25 were accurately coded to reflect Resident #5's diagnoses of schizophrenia (a chronic brain disorder causing distorted reality), seizures, and TBI (an injury to the brain caused by an external force leading to functional, physical, cognitive, emotional, or behavioral problems). This failure could place residents at risk for not receiving needed care and services to maintain the highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided accurate Preadmission Screening and Resident Review (PASARR) Screenings for 1 of 5 residents (Resident #5) reviewed for PASARR. The facility failed to ensure Resident #5 had an accurate PASARR Level 1 Screening which indicated a diagnosis of mental illness and refer Resident #5 to the state designated authority. This failure could place residents at risk of not receiving needed assessments (PASARR Evaluation), individualized care, and specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan within 48 hours of admission and provide the resident and or the resident representative with a summary of the baseline care plan for 1 of 5 residents reviewed for the base line care plans. (Resident # 93) The facility did not complete a baseline care plan within 48 hours of admission and provide a written summary of the baseline care plan to Resident # 93 or their responsible party. This failure could place newly admitted residents at risk of not receiving continuity of care and communication among nursing home staff, increase resident safety and safeguard against adverse events that are most likely to occur right after admission.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #45) reviewed for care plans. The facility failed to ensure Resident #45's care plan reflected her fingernail care needs and preference for eating her meals with her fingers and hands. This failure could place residents at risk of not receiving care and services to meet individualized medical and nursing needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for one of five residents (Resident # 45) reviewed for quality of life. The facility failed to ensure Resident #45 received nail care. This failure could place residents at risk for poor hygiene, dignity issues, and a decline in quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 2 residents (Resident #2) reviewed for Enhanced Barrier Precautions. CNA C failed to don PPE when she provided direct care for Resident #2 who required EBP.This failure could place residents under their care at risk for the transmission of communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to complete a required discharge summary for one of five residents reviewed for discharge (Resident #6). The facility failed to meet the requirement by not providing a completed discharge summary to the receiving healthcare facility for Resident #6. This failure could place residents at risk for not having continuity of care. Record review of Resident #6's undated face sheet indicated Resident #6 was admitted on [DATE] and discharged to another nursing home on [DATE]. Record review of Resident #6's medical record accessed on 12/10/2025 did not reveal a discharge summary. During an interview on 12/10/2025 at 1:30 PM, the ADON stated she did not know the facility's policy on discharge summaries. The ADON stated that she was told the SW and DON complete the discharge summary. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (Resident #1)The facility failed to prevent Resident #1 from sustaining a fall from the bed on 08/28/2025 which resulted in a fractured right femur. The noncompliance was identified as PNC (past noncompliance). The IJ began on 08/28/2025 and ended on 09/02/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of potential accidents, injuries, harm, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen observed for kitchen sanitation. The paper towel dispensers at the hand wash sink and employee restroom had no paper towels. The bulk flour bin had a large scoop stored inside the product on 09/16/24 and 09/17/24. The utensil drawer was soiled with food debris and dried liquid. A 25 lb. bag of brown sugar and 2-16 oz. bags of potato chips were opened and not re-sealed. The 3 compartment sink was not sanitizing and was being used. The 3 compartment sink and dish machine logs had been pre-filled with results for the entire day (09/16/24) when the noon and evening meals had not occurred. The results indicated temperatures and sanitizing conditions. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were completed and accurately documented for 1 of 4 residents (Resident #281) reviewed for medical records accuracy. The facility failed to ensure an order for enteral feedings (liquid nutrition delivered via a tube inserted into the body) from the hospital was documented in Resident #281 s physician's orders at the facility. The facility failed to document the administration of liquid nutrition for 4 consecutive days after Resident #281 was admitted to the facility. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary services to maintain acceptable grooming and personal hygiene for 2 of 3 residents reviewed for ADLs (Resident's #1 and Resident #2). The facility failed to ensure Resident #1's received a bath until 5 days after his admission. The facility failed to ensure Resident #2 received a bath/shower for 4 weeks. This failure could place dependent residents at risk for poor personal hygiene, skin infections and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident receives adequate supervision to prevent accidents for 1 of 2 residents reviewed for accident hazards (Resident #3). The facility failed to ensure Resident #3 had no history of elopement before accepting her as resident (the facility did not have a secure unit nor a wander guard system and thus would not accept residents with a history of elopement). The facility did not accurately assess Resident #3's physical ability to leave the facility upon her admission on [DATE]. This failure could place residents with recent at risk for inadequate supervision elopement and significant injury.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each residents' drug regimen was free from unnecessary psychotropic drugs (without adequate monitoring) for 1 (Resident # 1) of 4 residents whose medications were reviewed for pharmacy services. The facility failed to ensure Resident #1 was consistently and adequately monitored for adverse side effects of Lorazepam (medication used to treat anxiety, lorazepam belongs to a class of drugs known as benzodiazepines which act on the brain and nerves [central nervous system] to produce a calming effect). This failure could place residents at risk of possible medication side effects, adverse consequences, decreased quality of life, and dependence on unnecessary medications.

Inspectors wroteBased on 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 and mental status that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications for 1 of 4 (Resident #1) residents reviewed for resident rights. The facility failed to notify Resident #1's physician of elevated blood sugars resulting in her being sent to the emergency department unresponsive and with a blood sugar of 946 (normal blood sugar ranges are 70-110) This failure resulted in an identification of an Immediate Jeopardy (IJ) at 3:00 p.m. on 10/4/23. While the IJ was removed on 10/6/23 at 10:39 a.m. [...]

Inspectors wroteBased on 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 4 (Resident #1) residents reviewed for quality of care. 1. The facility failed to monitor Resident #1's condition following elevated blood sugar readings. 2. The facility failed to notify Resident #1's physician of elevated blood sugars resulting in her being sent to the emergency department unresponsive and with a blood sugar of 946 (normal blood sugar ranges are 70-110) 3. The facility's Diabetic Management policy failed to address high blood sugars. 4. The facility failed to include blood sugar parameters for physician notification in Resident #1's physician orders. These failures resulted in an identification of an Immediate Jeopardy (IJ) at 3:00 p.m. on 10/4/23. [...]

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 grooming and personal hygiene were provided for 3 of 9 (Resident #4, Resident #5, and Resident #6) residents reviewed for ADLs . 1. The facility failed to provide assistance with facial hair removal for Resident #4 and Resident #5. 2. The facility failed to ensure Resident #5's fingernails were trimmed. 3. The facility failed to provide scheduled showers to Resident #6 This failure could place residents at risk of not receiving services/care, decreased quality of life, and decreased self-esteem. Findings Include: 1. [...]

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 resident rights for 1 of 9 (Resident #5) residents reviewed for care plans, The facility failed to ensure Resident #6's refusal of care was care planned. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 2 of 4 (Resident #2 and Resident #3) residents reviewed for quality of care. 1. The facility failed to ensure Resident #2's tube feeding formula was labeled clearly with the correct formula. 2. The facility failed to ensure Resident #2's tube feeding water flush was labeled with the date and time it was started. 3. The facility failed to ensure Resident #3's tube feeding formula was labeled with the time and date it was started. These failures could place residents receiving tube feedings at risk of gastrointestinal disturbances (relating to the stomach and the intestines), and bacterial infection.

Inspectors wroteBased on interview and record review, the facility's interdisciplinary team failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment or no more than 21 days after admission for 1 of 5 residents (Resident #74) and failed to review and revise the person-centered care plan to reflect the current condition for 1 of 5 residents (Resident #74) reviewed for care plan revisions. The facility failed to review and revise Resident #74's baseline care plan within the required timeframe with a comprehensive care plan. This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observations, interviews, and record reviews. the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning is 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 #29) reviewed for oxygen therapy, in that: Resident #29's oxygen was set to 3 LPM on 3 consecutive days instead of 2 LPM as ordered by the physician. This failure could place residents who receive oxygen therapy at risk for respiratory distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure an accurate MDS assessment was completed for 1 of 5 residents (Resident # 21) reviewed for accuracy of MDS assessments. The facility failed to accurately code Resident # 21's antipsychotic medication usage on the MDS assessment. This failure could place residents at risk for not receiving needed care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for 1 of 2 residents (Resident #15) reviewed for gastrostomy tube management. The facility failed to ensure Resident #15's head of bed was elevated at a minimum of 30-degree angle during medication administration via gastrostomy tube (G-tube) (a tube directly inserted through the skin to the stomach to deliver nutrition). This failure could place residents who receive enteral feedings by G-tube at risk for injury, aspiration into the lungs (fluid or food enter the lungs accidently), decreased quality of life, hospitalization and decline in health.