Avir at Baird

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 3 of 39 days (06/20/2026, 06/21/2026 and 07/05/2026) reviewed for RN Coverage. The facility failed to have an RN onsite for 8 consecutive hours a day on 06/20/2026, 06/21/2026 and 07/05/2026. This deficient practice could place residents at risk of not receiving the advanced knowledge and skills of an RN to meet their individual needs to maintain health and well-being.

Inspectors wroteBased on interview and record review the facility failed to accurately complete a Preadmission Screening for individuals with mental disorder for 1 of 7 residents (Resident #5) reviewed for PASRR. The facility failed to accurately complete a PASRR Level I screening for Resident #5 who had a diagnosis of a mental illness. These failures could place the resident with a documented mental illness, intellectual and/or developmental disability at risk for not receiving needed services.

Inspectors wroteBased on interviews and record reviews the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care within 48 hours of a resident's admission for 1 (Resident #38) of 14 residents reviewed for care planning. The facility failed to develop a baseline care plan for Resident #38 within 48 hours of her admission. This failure could place newly admitted residents at risk of not receiving effective, person-centered care. [...]

Inspectors wroteBased on 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, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 6 residents (Residents #11) reviewed for care plans. The facility failed to ensure Resident #11 had a care plan in place for an implanted venous access port (a device surgically implanted for access to the circulatory system). This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 12 months ([DATE], [DATE], and [DATE]) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 5 days of 90 days in [DATE], [DATE], and [DATE]. This failure could place the residents at risk of not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 Nurse Aides (NA A and NA B) of 4 nurse aides reviewed for proficiency of nurse aides. The facility failed to ensure NA A and NA B were CNAs after four months of being hired. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being.

Inspectors wroteBased observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of 2 residents reviewed for Infection Control. The facility failed to ensure NA A performed hand hygiene and glove change while providing incontinent care to Resident #1 on 02/8/26. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet resident's highest practicable physical, mental, and psychosocial well-being for 3(Resident #1, Resident #11, and Resident #31) of 12 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of leg braces for Resident #1. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of intravenous antibiotics and infection for Resident #11. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of feeding tube for Resident #31. [...]

Inspectors wroteBased on interviews and records review, the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 5 (10/19/24, 10/20/24, 11/16/24, 11/17/24, 12/27/24) of 201 days reviewed. There was no RN coverage on the following dates: 10/19/24, 10/20/24, 11/16/24, 11/17/24, 12/27/24. This failure could place residents at risk for injury, decline or death during a situation requiring the advanced knowledge and skills of an RN to intervene and supervision of the direct care staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 2 (Resident # 1 and Resident # 11) of 12 Residents reviewed for accuracy of assessments. The facility failed to ensure MDS dated [DATE] reflected the use of a right and left leg brace for Resident #1. The facility failed to ensure MDS date 05/07/2025 reflected the use of antibiotics for Resident #11. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status.

Inspectors wroteBased on interview and record review, the facility failed to utilize the services of a Registered Nurse for at least 8 consecutive hours a day, seven days a week for 75 of 183 days reviewed for RN Coverage. The facility failed to provide evidence a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 65 days out of 92 days in Fiscal Year (FY) Quarter 1 2024 (October 1 - December 31) and 10 out of 91 days from January 1, 2024 to March 31, 2024. This failure could place residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 5 (Resident #8, Resident #9, Resident #19, Resident #26, and Resident #31) of 5 residents reviewed for care plans. The facility failed to develop care plans based on assessed needs with measurable objectives in areas such as pain management, weight loss or gain, urinary control, psychotropic medications, difficulty sleeping, implanted pacemaker, high blood pressure medications, blood thinning medications, and seasonal allergies for Resident #8. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure foods were sealed and/or labeled properly in dry food storage and freezers. The facility failed to properly thaw frozen meats to prevent unsafe temperature. These failures could place residents that eat out of the kitchen at risk for food borne illnesses.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 3 residents (Resident #16) reviewed for MDS information. The facility failed to encode, complete, and submit a discharge MDS for Resident #16. This failure could place residents at risk of facilities have provided resident specific information for payment and quality measure purposes.

Inspectors wroteBased on interview, and record review the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 (Resident #9, and Resident #185) of 7 residents reviewed for care plans. -The facility failed to ensure Resident #9's care plan accurately addressed intravenous antibiotic therapy. -The facility failed to ensure Resident #185's care plan addressed an accurate smoking status. These failures could affect residents of the facility by not accurately addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on record reviews and interviews, the facility failed to complete discharge summaries that included a recapitulation of the resident's stay including, but not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 3 residents (Resident #16) reviewed for discharge. The facility failed to provide Resident #16 with discharge summary when discharged from facility. This failure places residents at risk for incomplete and cohesive care after discharge from the facility.