Avir at Comfort

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's psychosocial needs for 3 of 3 residents (Residents #1, 2, and 3) reviewed for comprehensive care planning. The facility failed to ensure residents' preferences for activities and leisure were addressed in the comprehensive care plans for Residents #1, 2, and 3. This failure could result in decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents received an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 3 of 3 residents (Residents #1, #2, and #-3) reviewed for activities. The facility failed to ensure residents #1, #2, and #3 had the option of participating in daily, organized activities to meet the residents' psychosocial needs and preferences during May 2026. This failure could result in decreased psychosocial well-being or decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to use the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for nursing services. The facility did not utilize the services of an RN on 2/22/25, 2/23/25, 3/1/25, 3/30/25, 4/13/25, 4/20/25, 4/27/25, 5/4/25, 6/1/25, 6/8/25, 6/15/25, 6/29/25, 7/6/25, 7/13/25, 7/20/25, 7/27/25, 8/3/25, 8/10/25, and 8/17/25 for a total of 19 days. This failure could place residents at risk of not receiving needed care and services.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 3 residents (Resident #3) reviewed for quality of care. CNA A transferred Resident #3 using a mechanical lift without the assistance of another staff member. This failure could place residents at risk of accidents, injury, and pain.

Inspectors wroteBased on interview and record review the facility failed to provide nursing care with a sufficient number of nursing personnel on a 24-hour basis to all residents in accordance with resident care plans for 1 out of 4 days (04/07/25) reviewed for sufficient nursing staff. The facility failed to have sufficient staff available to provide resident care for approximately 5 hours during the 2P-10P shift on 04/07/25. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental and psychosocial wellbeing.

Inspectors wroteBased on interview and record review the facility failed to develop and implement comprehensive person-centered care plan for 1 of 5 Residents (Resident #1) whose records were reviewed, in that: Resident #1's Care Plan still reflected resident was a 1 person transfer when she was a 2-person transfer. The deficient practices could affect any resident and could result in the inaccuracy of assessments and contribute to residents not receiving care for identified care needs.

Inspectors wroteBased on interview 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 20 days (1/1/24, 1/6/24, 1/13/24, 1/14/24, 1/20/24, 1/27/24, 2/3/24, 2/4/24, 2/10/24, 2/17/24, 4/6/24, 4/21/24, 5/11/24, 5/12/24, 6/1/24, 6/2/24, 6/8/24, 6/9/24, 6/15/24, and 6/16/24), reviewed for nursing services. The facility had no RN coverage for 1/1/24, 1/6/24, 1/13/24, 1/14/24, 1/20/24, 1/27/24, 2/3/24, 2/4/24, 2/10/24, 2/17/24, 4/6/24, 4/21/24, 5/11/24, 5/12/24, 6/1/24, 6/2/24, 6/8/24, 6/9/24, 6/15/24, and 6/16/24. (20 days from January 2024 to June 2024) This failure could result in residents not receiving the required services to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents received services in the facility with reasonable accommodation of resident needs for 1 of 16 residents (Resident #13) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #13. This deficient practice could affect any resident and keep them from calling for help as needed.

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. The facility failed to ensure staff wore hair restraints to cover hair when in the kitchen. The facility failed to ensure staff with facial hair was covered by a hair restraint. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations and interviews, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility for 2 of 4 days (7/7/24 and 7/8/24), observed for postings. The facility did not have the survey results available and accessible to residents and visitors without having to ask for them on 7/7/24 and 7/8/24 during the survey period. This failure resulted in residents, family members, and legal representatives of residents being unable to access prior survey results without having to ask to see them.

Inspectors wroteBased on observation and interview, the facility failed to post the nurse staffing data on a daily basis at the beginning of each shift for 4 of 8 days (7/4/24, 7/5/24, 7/6/24, and 7/7/24) prior to and during the survey period, reviewed for nursing services. The daily staff posting was not posted on 7/4/24, 7/5/24, 7/6/24, and 7/7/24. (4 days) This failure could result in residents and visitors being unaware of facility staffing levels.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a Baseline Care Plan for resident 1 of 3 (Resident #6) who was admitted on hospice to the facility for respite care on 8/31/2023. The facility failed to initiate a Baseline Care Clan within 48 hours of admission date on 8/31/2023 to include information for the resident's stay for respite, for her hospice care, and for her stage 2 left heel wound while at the facility. This failure could place the resident at risk of not receiving person-centered care that is needed for communicating with staff to ensure the resident's needs are met.

Inspectors wroteThe 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 4 residents (Resident #10) reviewed for infection control. The facility failed to post a sign on Resident #10's door to indicate she was on Contact Isolation (any of the techniques used in addition to standard precautions that decrease the likelihood of infection by microorganisms transmitted through direct or indirect contact with the patient or patient care items, e.g., methicillin-resistant Staphylococcus aureus). This deficient practice could affect staff, residents, and visitors who may enter Resident #10's room without the appropriate PPE and expose them to infection.

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, in that: 1. The facility failed to ensure the facility fryer was clean and old oil discarded. 2. The facility failed to ensure homemade Jell-O was discarded after 3 days. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to complete a performance review of every nurse aide at least once every 12 months, and provide regular in-service education based on the outcome of these reviews for 4 (Lead CNA K, CNA E, CNA F, and CNA G) of 6 staff, in that; The facility failed to provide an annual performance review and subsequent trainings based on the outcome of the review for 4 (Lead CNA K, CNA E, CNA F, and CNA G) of 6 nurse aides reviewed for competencies. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 19 of 31 facility staff reviewed for trainings consistent with their expected roles, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with trainings consistent with their expected roles.

Inspectors wroteBased on interview and record review the facility failed to include effective communications as mandatory training for 17(DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 direct care staff reviewed for trainings, in that; The facility failed to provide the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with effective communications as mandatory training. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review the facility failed to ensure that staff members are educated on the rights of the resident and the responsibilities of a facility to properly care for its residents 19 (ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 facility staff reviewed for education records, in that;:: The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with education on the rights of the resident and the responsibilities of a facility to properly care for its residents. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review the facility failed to ensure that staff members are educated on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting incidents, and dementia management and resident abuse prevention, for 19 (ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O) of 31 facility staff reviewed for education, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with training that education on abuse, neglect, and exploitation and activities that constitute such actions, procedures for reporting allegations, and dementia management and resident abuse prevention. [...]

Inspectors wroteBased on interview and record review the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 19 of 31 facility staff reviewed for trainings on infection control, in that; The facility failed to provide the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O with trainings on infection control. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review the facility failed to communicate the compliance and ethics program's standards, policies and procedures through a training program or other practical manner which explains the requirements for 19 of 31 facility staff reviewed for education, in that; The facility failed to communicate the compliance and ethics program's standards to the ADM, the DON, the SW, the PT, OT L, OT M, CNA H, RN P, LVN B, Lead CNA K, CNA E, DA Q, CNA F, CNA G, the ACT DIR, LVN D, RN N, LVN C, and LVN O. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review, the facility failed to provide in-service training that was sufficient to ensure the continuing competence of nurse aides but must be no less than 12 hours per year and included dementia management training, resident abuse prevention training, and care of the cognitively impaired for 5 (CNA H, Lead CNA K, CNA E, CNA F, and CNA G) of 5 CNAs reviewed for annual training, in that; The facility failed to provide CNA H, Lead CNA K, CNA E, CNA F, and CNA G with 12 hours per year of annual training that included dementia management training, resident abuse prevention training, and care of the cognitively impaired. This failure could place residents at risk of being cared for by untrained staff.

Inspectors wroteBased on interview and record review the facility failed to have a system in place to assure assessments are conducted in accordance with the specified timeframes for each resident for 3 of 22 residents (#11, #25, #26) reviewed for MDS timeliness, in that; 1. Resident #11 discharged from the facility on 1/13/2023 however the resident's discharge MDS Assessment was not completed until 5/31/2023. 2. Resident #25 was discharged from the facility on 2/18/2023 however the resident's discharge MDS Assessment was not completed until 6/8/2028. 3. Resident #26 was discharged from the facility on 2/18/2023 however there was not a discharge MDS completed. These failures could result in incorrect billing to the residents' insurance and could prevent additional services the residents could receive in the community.

Inspectors wroteBased on interview and record review, the facility failed to ensure that an assessment was completed for residents within 14 days after a significant change in the resident's status for 1 of 22 residents (Resident #7) reviewed for MDS assessments, in that: The facility failed to complete a Significant Change MDS for Resident #7 within 14 days after the resident was discharged from hospice services. This deficient practice could place residents discharged from hospice services at-risk of not having their individual needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure each Minimum Data Set (MDS) was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 22 (Resident #25) residents reviewed for MDS transmittal in that: Resident #25's discharge MDS assessment dated [DATE] was not submitted as of 6/7/2023. This deficient practice could place residents at risk of not having their assessments transmitted timely.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete an accurate assessment of each resident's functional capacity for 1 of 22 residents (Resident #8) whose assessments were reviewed, in that: The facility identified Resident #8 had two stage 3 pressure ulcers on the resident's MDS Assessment however the resident did not have any stage 3 pressure wounds. This failure could place residents at risk of inadequate care due to inaccurate assessments.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a registered nurse signed and certified that the MDS assessment was completed for 1 of 22 residents (Resident # 25) reviewed for MDS completion, in that; The facility failed to ensure the RN signed Resident #25's discharge MDS assessment as completed. This failure could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's current status.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission for 1 of 22 residents (Resident #8) reviewed for care plans, in that; The facility failed to develop a baseline care plan within 48 hours for Resident #8 after the resident was admitted to the facility. This deficient practice could result in residents not receiving care and services as needed.

Inspectors wroteBased on interview and record review, the facility failed 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 a resident's mental, nursing, and psychosocial needs that were identified in the comprehensive assessment, for 1 of 22 Residents (Resident #8) reviewed for care plans, in that: 1. The facility failed to develop a comprehensive person-centered care plan that was specific for Resident #8 to address hospice information, details of hospice care provided and coordination of services. This failure could place residents at risk for not getting their medical, physical, and psychosocial needs met and not being provided with the necessary care or services and having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who was incontinent of bladder received appropriate treatment and services for 1 of 3 residents (Resident #23) reviewed for urinary catheters, in that: Resident #23 had an indwelling urinary catheter for 5 days without a physician's order or related care orders to be provided. This deficient practice could affect residents who had urinary catheters at risk of not receiving care needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse was present in the facility for at least eight consecutive hours per day and seven days per week, for 1 of 1 facility reviewed for registered nursing coverage, in that; A registered nurse [RN] was not present in the facility for at least eight consecutive hours per day and seven days per week on 4 occasions (4/01/2023, 4/08/2023, 4/15/2023, and 5/14/2023) in the 3 months (3/01/2023 - 6/04/2023) prior to the survey period. This deficient practice had the potential to affect all residents in the facility by leaving staff without supervisory coverage for coordination of events such as assessments, interventions, care and treatment requiring the advanced education, skills and judgement of an RN.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide routine drugs and biologicals to its residents, or obtain them for 1 of 12 residents (Resident #31) observed for pharmacy services, in that; The facility failed to obtain gabapentin medication as required for Resident #31. This deficient practice placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents are free of any significant medication errors for 1 of 12 residents (Resident #31) observed during medication administration, in that; The facility failed to administer medications (gabapentin, a medication to relieve nerve pain) as prescribed for Resident #31. This deficient practice placed residents at risk of inadequate therapeutic outcomes, increased negative side effects, and a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys in 1 of 3 medication carts (Treatment Cart) reviewed for medication storage, in that; The facility failed to ensure the Treatment Cart was locked when it was left unattended at the Nurses' Station in a common area. This deficient practice could place residents at risk of medication misuse or drug diversion.

Inspectors wroteBased on interviews, and record reviews the facility failed to maintain medical records on each resident that are complete; accurately documented; readily accessible; and systematically organized, for 1 of 22 residents (Resident #23) reviewed for accurate medical records, in that: Resident #23's electronic medical record did not have a diagnosis for her indwelling catheter. This failure could place residents at risk for harm due to inaccurate records.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 7 residents (Resident #2) reviewed for hospice services, in that: The facility failed to obtain Resident #2's copy of the hospice Plan of Care and a signed copy of the Hospice Election Form. This failure could place the residents who received hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.