Avir at Beaumont

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, for 1 of 2 living rooms for the secure Unit 300 (C and D Halls of the secure unit) and 1 of 7 (Resident #1 room) resident rooms reviewed for physical environment. The facility failed to ensure physical environment was clean and Hall C and Hall D living rooms was free of dirt, debris and sticky spots covering the floor. The facility failed to ensure Resident #1's bathroom was free of musty odor, dirty towel beside the toilet that was wet and discolored. The facility failed to ensure Resident #1 bedroom floor was clean and free of a crushed dead wood roach (an insect was brown with wings approximately 2 3/4 inch to 3 inches long and lives outside in trees) with a dark brown substance under the crushed wood roach. [...]

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 sanitation. 1. The facility failed to ensure the dishes were clean and sanitized.2. The facility failed to ensure equipment was clean and sanitized.3. The facility failed to label and date dry food items stored in containers.4. The facility failed to ensure the food was not stored past expiration date. These failures could place residents that eat out of the kitchen at risk for contamination and foodborne illnesses.

Inspectors wroteBased on interview and record review the facility failed to incorporate the recommendations from the PASRR Level II determination and PASRR evaluation report into the resident's assessment, care planning, and transitions of care for 1 of 2 (Resident #1) residents reviewed for PASRR services. -The facility failed to submit a complete and accurate request for nursing facility specialized services in the LTC Online Portal within 20 business days after the date of the Interdisciplinary Team meeting from 09/23/2025. This failure could place residents who have a mental health diagnosis, developmental disability, or intellectual disability at risk from not receiving services identified by the IDT in a timely manner.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents with loss of bladder control receive treatment or services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 6 residents reviewed for incontinent care. (Resident #1) The facility failed to provide Resident #1 assistance with timely incontinence care from 09:30 a.m. until 01:45 p.m. on 10/06/2025. This failure could place the residents at risk for decreased feelings of self-worth, skin breakdown, and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to establish a system of receipt and disposition of all controlled drugs in sufficient detail to enable accurate reconciliation and determine that drug records were in order and that an account of all controlled drugs were maintained for 1 of 7 residents (Resident #1) reviewed for controlled medications. The facility did not have documentation on Resident #1's July 2025 and August 2025 MARs indicating she was administered her Lorazepam (controlled antianxiety medication) prn when it was signed out on the controlled medication count sheet. The controlled medication count sheet did not indicate the medication doses were wasted. This failure could place residents at risk for medication overdose, medication under-dose, ineffective therapeutic outcomes, and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure its residents were free of any significant medication errors for 2 (Resident #1 and Resident #2) of 10 residents reviewed for medications. The facility failed to hold Losartan per parameters stated in physicians' orders for a total of 8 doses in July 2025 for Resident #1. The facility failed to hold Metoprolol per parameters stated in physicians' orders for 4 doses and Clonidine per parameters stated in physicians' orders for a total of 9 doses in July 2025 for Resident # 2. These failures placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings Included: 1. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure laboratory services were obtained to meet the needs of 1 of 6 residents (Resident #1) reviewed for laboratory services. The facility failed to ensure Resident #1's Comprehensive Metabolic Panel, also known as CMP (a blood test that checks for a wide range of substances in your blood, including proteins, enzymes, electrolytes, and minerals), Complete Blood Count also known as CBC (a blood test that measures amounts and sizes of your red blood cells, hemoglobin, white blood cells and platelets), carcinoembryonic antigen also known as CEA (blood test measures the level of a specific protein in the blood, primarily used to monitor certain types of cancer), Thyroid-Stimulating Hormone also known as TSH (blood test to assess level of thyroid stimulating hormone and thyroid function and metabolism) and Thyroxine test also [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 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 caused the allegation involved abuse or result 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 State Survey Agency in accordance with State law through established procedures for 2 of 4 residents (Resident #3 and #4) reviewed for reporting allegations of abuse. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse and neglect for 2 of 3 residents (Resident # 47, Resident #87, and Resident #106) reviewed for abuse. The facility failed to ensure Resident #47 was free from sexual abuse when Resident #106 touched her face, hair, and breast area inappropriately on 05/28/2025. The facility failed to ensure Resident #87 was free from physical abuse when Resident #87 and Resident #106 had a physical altercation on 06/05/2025. The noncompliance was identified as PNC. The IJ began on 05/28/2025 and ended on 06/05/2025. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for emotional distress, fear, decreased quality of care, and further abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 2 of 3 resident (Residents #87 & #106) reviewed for accidents hazards and supervision. 1. The facility failed to provide adequate supervision on the facility's memory care unit, to prevent Resident #87, who had severe cognitive impairment from wandering into Resident #106 room at approximately 4:00 a.m. on 06/05/25. 2. The facility did not implement interventions to include adequate supervision prior to the incident or following the incident for all residents at risk for injuries related to wandering behaviors. An Immediate Jeopardy (IJ) was identified on 06/19/25 at 4:50 p.m. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 laundry room reviewed for essential equipment. The facility did not ensure 4 of 4 dryers were working in safe operating condition. This failure could place the residents at risk not receiving their clothes in a timely manner.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 residents out of 21 residents reviewed for environmental concerns in their rooms, 2 of 3 linen closets for adequate linen, 2 of 3 Halls for intact windows and courtyard for environment. 1. The courtyard used by the residents was unkempt and had tall grass, and weeds, and had trash in the weeds and in the bushes. 2. Resident #36 and Resident #41 rooms had an unrepaired trim and wall with missing paint and deep gouges in the sheet rock. 3. Linen closets were not stocked with white linen and linen was discolored with stains, and thin, and worn. 4. Hall 100 and 200, next to the exit door, had broken glass pane with cardboard and tape. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 3 errors out of 27 opportunities, resulting in an 11.11% percent medication error involving 1 of 4 residents reviewed for medication pass. (Resident #28) LVN P administered Primidone (used to treat tremors) at 7:50 a.m. (the physician ordered Primidone be given daily at hour of sleep) and administered Artificial Tears 2 drops each eye instead of the ordered Pataday eye drops (itch relief eye drops) 1 drop each eye for Resident #28. These failures could place residents at risk for inaccurate drug administration resulting in decline in health and decreased quality of life.

Inspectors wroteBased on interviews, and record reviews, the facility failed provide sufficient support personnel to carry out the functions of the food and nutrition service safely and effectively for 3 out of 12 dietary staff (Dietary staff D, Dietary staff B, and Dietary staff C). The facility did not ensure Dietary staff D, Dietary staff B, or Dietary staff C had current food handler permits. This failure could place residents who consumed food prepared from the kitchen at-risk of foodborne illness or nutritional deficiencies.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 staff smoking area reviewed for environmental concerns. The designated staff smoking area was unkempt and had trash buried in the tall grass and weeds, This failure placed the staff and visitors at risk of uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #2) reviewed for enteral feeding. The facility failed to ensure LVN Q mixed each crushed medications with water and administered one medication at a time when giving medications to Resident #2 through his G-tube (a tube inserted through the wall of the abdomen directly into the stomach which allows the delivery of nutrition, fluids, and medications directly into the stomach). The facility failed to ensure LVN Q administered Resident #2's G-tube medications by gravity, and instead she pushed the medications using the plunger of the syringe. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles and provide separately locked, permanently affixed compartments for storage of controlled drugs for 1 of 21 residents (Resident #64) and 1 of 3 medication rooms reviewed for storage of medications and biologicals. 1. The facility failed to ensure the lockbox for controlled medications was permanently affixed to the refrigerator in the Hall 300 medication room. 2. The facility failed to ensure Resident #64's medication was secured inside the locked medication cart in the women's unit on Hall 300. These failures could place residents at risk of not receiving prescribed drugs or contaminated medication.

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 1 of 2 residents reviewed for infection control. (Resident #49) The facility failed to ensure CNA S performed proper hand hygiene while assisting to feed Resident #49. This failure could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 2 of 2 resident rooms (Room #s 230 and 231) and 1 of 2 shower rooms (Unit 100 Hall D shower) reviewed for physical environment. 1. The facility did not ensure the shower room on 100 D Hall was in good repair and in good working condition. 2. The facility failed to ensure two of two resident nightstands and rooms on Unit 2 were treated for cockroaches. These failures could place the residents at risk for decreased quality of life and infection due to unsafe and unsanitary conditions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests in 2 of 2 resident rooms. The facility failed to ensure two of two resident nightstands and rooms on Unit 2 were treated for cockroaches. This failure could place residents at risk for an unsanitary environment and a decreased 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 service safety for 1 of 3 dining rooms and 1 of 1 kitchen reviewed for sanitation. (Main dining room) The facility failed to ensure an air conditioner return air vent in the dining room was free of dust particles. The facility did not ensure kitchen equipment was sanitary and in good repair. This failure could place the residents at risk of food borne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the status for 2 of 28 residents reviewed for assessments. (Residents #13 and #109)). The facility failed to complete an accurate resident assessment for Resident #13. Resident #13's resident assessment did not reflect she was a tobacco user. The facility failed to complete an accurate resident assessment for Resident #109. Resident #109's resident assessment did not reflect her active diagnosis of anxiety disorder. This failure could place residents at risk of not having individual needs met and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion for 1 of 24 resident reviewed for range of motion. (Resident #7) The facility did not ensure Resident #7's splint was placed in her contracted right hand. This failure could place the residents at risk of not receiving the care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 2 errors out of 25 opportunities which resulted in an 8 percent error rate involving Residents' #58 and #92. LVN O administered Resident #58's midodrine HCL 5 mg (a medication used to treat low blood pressure) when the blood pressure was outside the prescribed parameters. LVN P administered Resident #92's clopidogrel 75 mg (a medication used to thin blood and prevent clotting) over 3 hours past the administration time frame listed on the medication administration record, according to the facility's policy that medications are scheduled according to the routine schedule of 7am. This failure could place residents at risk of not receiving the therapeutic benefits of their medications as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove and the convection ovens were in safe operating condition. This failure could place the residents at risk of a fire and not receiving their meals timely.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training effective communications mandatory training was completed for 6 of 21 employees (LVN F, ST, PT, CNA K, CNA M, and the HS) reviewed for training. The facility did not ensure effective communication training was completed by LVN F, ST, PT, CNA K, and CNA M during orientation. The facility did not ensure effective communication training was completed by the HS annually. These failures could place residents at risk of miscommunication and social isolation due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure the rights of the resident and responsibilities of the facility were completed for 3 of 21 employees (OT, CNA M, and HS) reviewed for training. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by OT and CNA M during orientation. The facility failed to ensure the rights of the resident and responsibilities of the facility training was completed by HS annually. These failures could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure employees received the required training on Abuse, Neglect, and Exploitation (ANE) for 2 of 15 (OT and HS) and dementia management for 2 of 15 employees (OT and LVN C) reviewed for training. The facility did not ensure dementia management training was completed by the OT and LVN C during orientation. The facility did not ensure ANE training was completed by the OT during orientation. The facility did not ensure ANE training was completed by the HS annually. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate training when caring for dementia residents.

Inspectors wroteBased on interview and record review, the facility failed to ensure Quality Assurance and Performance Improvement (QAPI) training that outlines and informs staff of the elements and goals of the facility's QAPI program was completed for 15 of 21 employees (Administrator, BOM, DON, ST, PT, SW, AD, LVN C, LVN D, LVN F, CNA G, CNA H, CNA J, CNA K, CNA L and CNA M) reviewed for training. The facility did not ensure QAPI training was completed by the Administrator, BOM, DON, ST, PT, SW, AD, LVN C, LVN D, LVN F, CNA G, CNA H, CNA J, CNA K, CNA L and CNA M. This failure could place staff and residents at risk for not being aware of facility programs, implementation, and monitoring.

Inspectors wroteBased on interview and record review, the facility failed to ensure standards, policies, and procedures for an infection prevention and control program was completed for 4 of 21 staff (LVN C, OT, HS, and CNA M) reviewed for training. The facility did not ensure infection prevention and control training was completed by the OT, CNA M, and LVN C during orientation. The facility did not ensure infection prevention and control training was completed by the HS annually. These failures could place residents at risk of illness due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure compliance and ethics training was completed for 21 of 21 employees (Administrator, BOM, DON, ADON, ST, OT, PT, SW LVN D, LVN E, LVN F, CNA G, CNA H, CNA J, CNA K, CNA L, and CNA M) reviewed for training. The facility did not ensure compliance and ethics training was completed for the BOM, ADON, LVN C, LVN D, LVN F, ST, OT, PT, SW, MD, CNA K, CNA L, and CNA M during orientation. The facility did not ensure compliance and ethics training was completed by the Administrator, DON, LVN E, AD, HS, CNA G, CNA H, and CNA J annually since the company had a total of 6 facilities. This failure could affect residents and place them at risk of poor care or victimization due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to ensure training on behavioral health was completed for 4 of 21 employees (Administrator, OT, LVN C, and CNA M) reviewed for training. The facility did not ensure behavioral health training was completed by the OT, LVN C, and CNA M during orientation. The facility did not ensure behavioral health training was completed by the Administrator annually. This failure could place residents with behaviors at risk of not receiving care to attain or maintain their highest practicable physical, mental, and psychosocial well-being due to lack of staff training.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to consult with the resident's physician when there was a need to alter treatment for 1 of 24 residents (Resident #92) reviewed for notification of changes. The facility failed to ensure the physician was notified of a missed dose of Oxacillin (used to treat bacterial infections) 1gm IV Q6H x 5 days was to start at 6:00 a.m. on 04/30/24 and unable to start the prescribed Oxacillin for Resident #92. The facility failed to ensure the physician was consulted when the pharmacy indicated the Oxacillin was outside of the recommended dose or frequency. This failure could place residents at risk of not receiving appropriate medical treatments, which could result in severe illness or hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, clean and homelike environment for 1 of 24 residents (Resident #92) reviewed for environment. The facility failed to provide Resident #92 with a thoroughly clean room without other resident's personal belongings in his room. This failure could place residents at risk of unclean, unhomelike environment and a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to refer residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change of condition to the State-designated authority for 1 of 12 residents (Resident #109) reviewed for PASRR. The facility did not refer Resident #109 to the LMHA when the NP provided a new mental illness diagnosis of anxiety. This failure could place residents at risk of not receiving the needed PASSAR services to meet their individual needs and could result in a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure preadmission screening for individuals identified with MI, DD, or ID were evaluated for services for 1 of 24 residents reviewed for resident assessments (Resident #415). The facility did not have an accurate PASRR level 1 screening (PL1) for Resident #415 upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure pharmaceutical services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 24 residents reviewed for physician orders. (Resident #92) The facility failed to follow physician orders related to ferrous gluconate (used to treat or prevent low blood levels of iron) for Resident #92. This failure could place the residents at risk of not receiving care and services as ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs when used without adequate monitoring for 2 of 24 residents reviewed for unnecessary medication. (Residents #58 and #415) The facility failed to hold Resident #58's midodrine hcl (used to treat low blood pressure) when the resident's blood pressure was outside parameters set by the physician from 04/01/24 to 04/29/24. The facility failed to monitor Resident #415 for side effects from 04/12/24 to 04/29/24 of the anticoagulant medication Eliquis (a blood thinning medication). This failure could place residents at risk of complications and not receiving the intended therapeutic effects of their medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure based on the comprehensive assessment of a resident, residents who use psychotropic drugs received gradual dose reduction and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for 1 of 24 residents (Resident #415) reviewed for unnecessary medications. The facility failed to monitor Resident #415 for side effects of the antipsychotic medication quetiapine fumarate and Abilify and the antianxiety medication buspirone hcl. This failure could place residents at risk for adverse consequences such as dizziness, drowsiness, oversedation, agitation, restlessness, and suicidal thoughts related to the use of psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure CNAcans completed Abuse, Neglect, and Exploitation (ANE) and dementia management trainings for 1 of 6 CNAs (CNA M) revicanewedreviewed for training. The facility did not ensure ANE and dementia management trainings were completed by CNA M during orientation. This failure could place residents with dementia at risk of abuse, neglect, and exploitation and a poor quality of care by staff with inadequate trainincang when caring for dementia residents.

Inspectors wroteBased on interview and record review, the facility failed to provide a 30-day notice to the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand before the resident was discharged for 1 of 1 (Resident #101) reviewed for Discharge Rights. The facility did not provide a written discharge notice to Resident #101 (who admitted on [DATE] and discharged on 08/30/23) or their representative prior to discharging the resident, not allowing the 30-day advance notice. The facility discharged Resident #101 to a behavioral hospital. This failure could place residents who are transferred or discharged from the facility, at risk for not receiving care and services to meet their needs upon discharge and the right to appeal.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents reviewed for a written plan of care received care and services as ordered by the physician for 3 of 23 residents. (Resident #22, #64 and #109) The facility failed to follow physician orders related to a blood pressure medication for Resident #22. The facility failed to follow physician orders related to blood pressure medication for Resident #64. The facility failed to initiate physician orders related to new order for anticoagulant for Resident #109. This failure could place the residents at risk of not receiving care and services as ordered by the physician.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 of 23 residents reviewed for respiratory care and services. (Resident #100) The facility failed to administer the correct dose of oxygen to Resident #100. This failure could place the residents at risk for not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 23 residents reviewed for medications. (Resident #22 and #64) Resident #22 missed several doses of a PRN blood pressure medication when her blood pressure was extremely elevated. Resident #64 received the antihypotension medication when it should have not been given and it was held when it should have been given on multiple occasions This failure could place resident at risk of not receiving medications as prescribed and/or significant medication errors.