Avir at Center

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents maintained the right to receive visitors of his or her choosing at the time of his or her choosing for 1 of 1 facility. The facility failed to ensure all residents had the right to receive visitors between 10:00 PM and 6:00 AM.The deficient practice could place residents at risk of isolation, decreased emotional well-being, and diminished 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 2 of 6 residents (Resident #10 and Resident #17) and 2 of 5 staff (LVN A and CNA B) reviewed for infection control. The facility failed to ensure LVN A and CNA B followed enhanced barrier precautions for Residents #10 and #17 on 07/21/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

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 kitchen reviewed for essential equipment. The facility did not ensure the gas stove was in safe operating condition with the pilot light burner staying lit for 1 of 6 burners and allowing gas to leak on 07/21/25 and 07/22/25. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relays the call directly to a staff member or a centralized staff work area from toilet and bathing facilities for 1 of 4 residents reviewed for call lights. (Resident #11). The facility failed to ensure Resident #11's emergency call light in the bathroom would reach the floor. The call light cord for Resident #11 was three feet above the floor level. This failure could place residents at risk of not receiving timely assistance.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident, in 3 of 11 resident rooms reviewed for required square footage. (Resident room #s 300, 309 and 310). The facility did not have at least 80 square feet per resident in resident room #s 300, 309, and 310. This failure could place residents at risk of having inadequate space for personal belongings, guests, and limit the resident's ability to move about in the room. Based on observation, interview, and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident, in 3 of 11 resident rooms reviewed for required square footage. (Resident room #s 300, 309 and 310). The facility did not have at least 80 square feet per resident in resident room #s 300, 309, and 310. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents. The facility failed to prevent Resident #1 from eloping on 7/23/2024 when he was able to exit the secured unit and exited the facility through the main entrance. The noncompliance was determined to be PNC (past non-compliance) . The IJ (Immediate Jeopardy) began on 7/23/24 and ended on 7/23/24. The facility had corrected the noncompliance before the survey began. These failures could place residents at risk for serious injury and accidents.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment that did not result in bodily injury were reported to the state agency within 24 hours for 1 of 7 residents (Resident #1) reviewed for abuse and neglect. The Administrator failed to report to the state agency withing 24 hours concerning an allegation of neglect on 07/23/2024 when Resident #1 eloped from the secured unit out of the entrance doors to the unit and out of the front entrance of the facility. This failure could place residents at risk for harm and injury.

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 the facility's only kitchen reviewed for food safety requirements and kitchen sanitation 1. The dietary aide failed to effectively wear a hair net to cover all her hair on 6/03/2024 and 6/04/2024. 2. The facility failed to ensure foods stored in the refrigerator and freezer were labeled, dated, and not kept past their expiration dates. 3. The cook and dietary manager failed to properly perform hand washing when performing duties in the kitchen. These failures could place residents at risk of foodborne illness and food contamination.

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 2 of 6 residents (Resident #34 and #25) and 2 of 4 staff (CNA E and CNA G) reviewed for infection control. The Hospice Aide did not follow enhanced barrier precautions when she provided care to Resident #34 on 6/3/2024. CNA C did not sanitize or wash her hands between glove changes and wiped a female resident from back to front when providing incontinent care to Resident #25 on 6/4/2024. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed 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 4 residents (Residents #19) reviewed for respiratory care. The facility failed to ensure Resident #19's oxygen tubing was changed per the physician orders. These deficient practices could place residents at risk of developing respiratory infections and complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident, in 5 of 18 resident rooms reviewed for required square footage. (Resident room #s 300, 306, 308, 309 and 310). The facility did not have at least 80 square feet per resident in resident room #s 300, 306, 308, 309, and 310. This failure could place residents at risk of having inadequate space for personal belongings, guests, and limit the resident's ability to move about in the room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were stored in accordance with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 2 of 2 medication carts (nurse cart unit 1 and unit 2) and 1 of 2 medication storage rooms (unit 2) reviewed for labeling and storage. The facility failed to remove expired insulin from the nurse medication cart on unit 1 and unit 2 for Resident # 11 and Resident # 21. The facility failed to remove expired tuberculin PPD (purified protein derivative) Mantoux testing solution from the medication storage room on unit 2. These failures 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 promote care for residents in a manner and in an environment that maintained or enhanced each resident's dignity for one (Resident #19) of three residents reviewed for dignity in that: The facility failed to ensure Resident #19's feeding pump had a dignity/privacy cover while out of her room. This deficient practice could place residents in the facility at risk for a diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on interview and record review the facility failed to refer all 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 for 1 of 4 Residents (Resident #19) reviewed for PASSAR (Preadmission Screening and Resident Review Services). The SW failed to refer Resident #19 for a resident review after being diagnosed with bipolar disorder current episode manic severe with psychotic features. The onset of the diagnosis was 3/11/2022. This deficient practice could place residents at risk of not receiving the needed PASSAR services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications for 1 of 5 residents (Resident # 2) reviewed for medication administration. LVN C failed to administer Resident # 2's water flush through his feeding tube as ordered by the physician with medication administration. This failure could place residents who receive medications through a feeding tube at risk of not receiving the intended therapeutic benefit of the medications.

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 1 resident's reviewed for infection control. The facility failed to ensure that the urinary catheter bag for Resident #2 did not touch the floor. This failure could place residents at risk for infection. Findings Included: Record review of Resident #2's face sheet dated 5/2/23 revealed a [AGE] year-old male originally admitted to the facility on [DATE] and most recent admission on [DATE] with diagnoses including: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure bedrooms measured at least 80 square feet per resident, in 5 of 18 resident rooms reviewed for required square footage. (Resident room #s 300, 306, 308, 309 and 310). The facility did not have at least 80 square feet per resident in resident room #s 300, 306, 308, 309, and 310. This failure could place residents at risk of having inadequate space for personal belongings, guests, and limit the resident's ability to move about in the room.