Avir at Commerce

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain medical records, in accordance with accepted professional standards and practices, which are complete, and accurately documented for 1 of 4 (Resident #1) residents reviewed for medical records. The facility failed to document and record in the electronic medical record attempts at titration (gradual reduction) of Resident #1's oxygen rate according to physician's order. This failure could place residents at risk of inaccurate and complete records.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person centered care plan for 3 of 3 residents reviewed for care plan. The facility failed to implement the intervention to keep glasses clean for Residents #1 and Resident #3. The facility to develop a care plan with interventions for Resident #2's eyeglasses to ensure they stay clean. This failure could place residents at risk of falls and decrease quality of life.

Inspectors wroteBased on interview and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis or have a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for nursing services. The facility did not have 8 hours of RN coverage for 17 of 121 days (10/10/25, 10/11/25, 10/12/25, 10/16/25, 10/17/25, 10/18/25, 10/19/25, 11/15/25, 12/01/25, 12/14/25, 12/21/25, 12/25/25, 01/18/26, 01/24/26, 01/27/26, 01/28/26 and 02/06/26). The facility did not have a designated DON to work full time of at least 40 hours a week from 01/20/26 till current (02/12/26). This deficient practice could place 49 residents at risk of not receiving adequate care by not having staff available with the ability to perform assessments as needed.

Inspectors wroteBased on observation, interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 3 of 3 residents (Residents #17, #12, and #16) reviewed for PASRR. 1. The facility failed to provide documentation of Residents #17 and #16's habilitation coordination as requested in the PCSP Form. 2. The facility failed to provide documentation of Resident #12's independent living skills services as requested in the PCSP Form. These failures could cause residents with mental health disorders and psychiatric conditions to have a delay in services or not receive specialized services or equipment that may be 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 and 1 of 2 residents (Resident #23 and Resident #35) reviewed for food safety. 1. The facility failed to ensure they had pasteurized eggs in the refrigerator. 2. The facility failed to ensure the Maintenance Supervisor wore a hairnet and beard guard while in the kitchen on 02-09-26. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish policies regarding smoking areas, and smoking safety for 1 of 1 smoking area reviewed for physical environment. 1. The facility failed to provide a metal container with a self-closing cover device. 2. The facility did not ensure smoked cigarettes were extinguished in a fire-retardant receptacle. This failure could place residents at risk of unsafe smoking and injury. Findings Included:During an observation on 02/10/26 at 6:01 p.m., a group smoke break of five residents smoking revealed cigarette butts on the ground outside in the smoking area, trash in the red noncombustible cigarette butt receptacle can, and the self-closing ashtray was malfunctioning. During the observation cigarettes were put on top of the self-closing ashtray with other old cigarette butts. [...]

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 good nutrition, grooming, personal and oral hygiene for 1 of 18 (Resident #40) residents reviewed for ADL care. 1. The facility did not ensure Resident #40 was provided with his scheduled bath/showers. 2. The facility did not ensure Resident #40's fingernails were trimmed and free from a black colored substance routinely. These failures could place residents at risk of not receiving services or care, decreased quality of life, and decreased self-esteem.

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 for 1 of 18 residents (Resident #3) reviewed for accidents hazards. The facility did not ensure acetone was not stored on Resident #3's dresser on 02/10/26. This failure could place residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for 1 of 1 resident (Resident #23) reviewed for treatment and services related to indwelling catheters. The facility failed to ensure Resident #23's foley catheter (tube inserted into bladder) was secured on 02/10/26, 02/11/26, and 02/12/26. This failure could place residents at risk for urinary tract infections and a decreased quality of life.

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, and the residents' goal and preferences for 1 of 2 residents (Resident #40) reviewed for oxygen therapy. The facility failed to have Resident #40's oxygen sign outside the door on 02/09/26, 02/10/26, 02/11/26, and 02/12/26. This failure could place residents who receive respiratory care at risk for respiratory infections including pneumonia, shortness of breath and even death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food and drink that accommodated the residents' preferences for 1 of 23 residents (Resident #16) reviewed for preferences. The facility did not honor Resident #16's preference for no lima beans on 02/09/26. This failure could place residents at risk for a decrease in residents' choices and weight loss.

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 1 resident (Resident #14) reviewed for hospice services. The facility did not ensure Resident #14's hospice records were a part of their records in the facility. This deficient practice could place residents at risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

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 to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #6) reviewed for infection control. The facility failed to ensure CNA B and CNA H followed EBP and put on gown and gloves while providing incontinent care to Resident #6 on 02/11/26. 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, comfortable, and homelike environment for 1 of 12 resident rooms (Resident #16) reviewed for physical environment. The facility failed to ensure Resident #16's windowsill was in good repair without exposed and splintered wood. This failure could place residents at risk for further deterioration, uncomfortable temperatures, the inability to properly clean, and possible pest infestation.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient number of nursing staff on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans and the facility assessment for 1 of 1 facility reviewed for care and services. The facility failed to provide sufficient CNAs according to the facility assessment on 02/01/2025, 02/04/2025, 02/05/2025, 02/06/2025, 02/07/2025, 02/08/2025, 03/01/2025, 03/07/2025, 03/10/2025, 03/12/2025, 03/25/2025, 03/29/2025, 04/01/2025. This failure placed residents at risk of inadequate supervision, an unsafe environment, falls, serious harm and injury, exacerbations of disease processes, abuse, and death.

Inspectors wroteBased on interview and record review the facility failed to treat each resident with respect and dignity and provide care in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 5 residents (Resident #1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated respectfully when CNA B spoke to Resident #1 in a loud manner and patted her hand on 04/14/2025. This failure could place residents at risk of embarrassment, feelings of worthlessness, decreased self-worth, loss of dignity, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 2 medication carts (South Hall Nurse Medication Cart) reviewed for drugs and biologicals. The facility failed to ensure LVN C secured the South Hall Nurse Medication Cart, when it was not in use on 05/07/2025. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on observation, interviews, and record review the facility failed to ensure residents have the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives and to choose the option he or she prefers for 2 of 5 residents reviewed for the right to be informed. (Resident's #1 and #9) 1. The facility failed to ensure Resident #1's psychotropic consent for trazadone (antidepressant), Xanax (antianxiety), lorazepam (antianxiety), and sertraline (antidepressant) reflected the clinical indication for use, the benefits of the medication, and the statement of consent. 2. The facility failed to ensure Resident #9's psychotropic consent form for Zyprexa (antipsychotic) reflected the resident or resident representative's signature for consent. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to promptly resolve grievances for 3 out of 24 residents (Resident's #42, #44, #47) reviewed for grievances. The facility did not ensure Resident's #42, #44, and #47 grievances concerning coffee temperature were addressed. This deficient practice could place the residents at risk for decreased quality of life and feelings of neglect.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents who required dialysis (treatment that filters water and waste from the blood when the kidneys are no longer able to do so) received such services, consistent with professional standards of practice for 1 of 1 resident (Resident #49) reviewed for dialysis. The facility failed to ensure all pre and post-dialysis assessments were completed for Resident #49. This deficient practice could affect residents who received dialysis treatments and place them at risk for complications and not receiving adequate care and treatment to meet their needs.

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 and periodically reconciled for 1 of 1 storage area reviewed for expired and discontinued medications. The facility failed to keep a record of receipt of controlled medications awaiting disposition to allow accurate and periodic reconciliation. This failure could place residents at risk for loss of prescribed medications, resident's safety, and drug diversion.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the meals served met the nutritional needs of residents for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy. The facility did not ensure an 8 oz scoop size was used to serve the chicken alfredo during the lunch meal on 11/05/24. This failure could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 4 of 19 residents (Resident's #22, #42, #44, and #47) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident #22, #42, #44, and #47 who complained the food was served cold, was bland, and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to effectively 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, including hand hygiene for 3 of 7 residents (Resident #48, Resident #44 and Resident#3) reviewed for infection control. 1. The facility failed to ensure LVN H changed gloves or performed hand hygiene while providing wound care for Resident #48's coccyx area. 2. The facility failed to ensure CNA F did not wear Personal protective equipment and gloves in the hallway after assisting Resident #44 with his breakfast tray who was in contact isolation. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for 1 of 1 smoking area. The facility failed to ensure flammable paper products (empty cigarette box, piece of a paper towel, blue sticky note, and a sonic cup) were not discarded in the red metal trash can designed for the disposing of cigarette butts. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment. Findings Included: During an observation on 11/5/24 at 8:24 a.m., 4 residents were outside in the smoking area smoking with staff present. There was a red smoking can with cigarette butts, an empty cigarette box, piece of a paper towel, blue sticky note, and a sonic cup. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure the right to formulate an advanced directive was provided for 2 of 19 residents (Residents #40 and #44) reviewed for advanced directives. 1. The facility did not ensure Resident #40's OOH-DNR included the physician signature and licensed number. 2. The facility did not ensure Resident #44's full code status was discontinued after Resident #44 signed a DNR. These failures could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 19 residents (Resident #42) reviewed for reasonable accommodation of needs. The facility did not ensure Resident #42 was able to easily use the door to her room. This failure could place residents at risk for unmet needs and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide appropriate treatment and service of care for 1 of 3 residents (Resident #30) reviewed for indwelling catheter. The facility failed to ensure Resident #30's indwelling catheter securement device was in place. The facility failed to ensure Resident #30's indwelling catheter drainage bag was kept from touching and resting on the floor. These failures could affect residents with an indwelling urinary catheter and place them at risk of at risk for urethral tears, discomfort, infection, and hospitalization.

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, and the resident's goals and preferences for 2 of 5 residents (Resident's #15 and Resident #11) reviewed for respiratory care. 1. The facility failed to ensure Resident #11's oxygen was placed on 2 liters per nasal cannula as ordered by the physician. 2. The facility failed to change oxygen tubing weekly on Sunday nights for Resident #11 and Resident #15. These failures could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 1 of 3 residents (Resident # 49) reviewed for trauma-informed care. The facility did not ensure Resident #49 had a trauma screening upon admission that identified possible triggers when Resident 49 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that it was free of medication error rate of 5 percent or greater. The facility had a medication error rate of 24.24%, based on 8 errors out of 33 opportunities, which involved 2 of 6 residents (Resident #4 and Resident #25) reviewed for medication administration. The facility failed to ensure Resident #4 medications were administered during the scheduled time on 11/04/24. The facility failed to ensure LVN appropriately dosed Resident #25's MiraLAX on 11/05/24. These failures could place residents at risk for not receiving the intended therapeutic benefit of their medications or receiving them as prescribed, per physician orders.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were free of significant medication errors for 1 of 6 residents (Resident #4) reviewed for pharmacy services. The facility failed to ensure Resident #4 medications were administered during the scheduled time of 6:00 AM and 10:00 AM on 11/04/24 which resulted in medications being administered 1 hour and 36 minutes late after the 1-hour grace period. The facility failed to ensure Resident # 4's medications were administered during the scheduled time of 6:00 AM and 10:00 AM on 11/05/24 which resulted in medications being administered 4 hour and 55 minutes late after the 1-hour grace period. These failures could place residents at risk of medical complications and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on observation and interview the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel, and labeled and dated correctly for 1 of 4 medication carts (south nurse's treatment cart) and 2 of 7 residents (Resident #3) observed for medication storage. 1. The facility did not ensure the south side nurse's treatment cart was secured and unable to be accessed by unauthorized personnel on 11/05/24. 2. The facility failed to ensure Resident #3's insulin lispro pen was properly secured when LVN B left it on top of the nurse's treatment cart on 11/05/24. 3. The facility failed to ensure Resident #38 wound care supplies was properly safe and secured. These failures could place residents at risk for not receiving drugs and biologicals as needed and a drug diversion.

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 2 residents (Resident #1) reviewed for hospice services. The facility did not ensure Resident #1's updated plan of care and most recent medication list from the hospice were a part of their current medical records in the facility. This deficient practice could place residents who receive 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.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 3 doors reviewed for a safe environment. The facility failed to ensure the wander guard system operated correctly on the north side door when the Maintenance Supervisor tested the door on 11/07/24. This failure could place residents at risk of elopement, injury, or harm.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide residents with a nourishing, palatable, well-balanced diet that meets their daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 1 meal (the lunch meal) reviewed for nutritional adequacy. The facility failed to prepare an adequate amount of food for the lunch meal on 10/29/24. This failure could affect all residents in the facility by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health.

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 6 (Resident #2) residents reviewed for notification of change. The facility failed to notify Resident #2's physician of a weight loss of 9.8 lbs. in 8 days. These failures could result in residents with weight loss not receiving treatments, supplements, or nutrition needed to maintain acceptable and desired weight and nutritional needs for healing. Findings Include: 1. [...]

Inspectors wroteBased on observation , interview, and record review the facility failed to ensure parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician ordersto help prevent the development and transmission of communicable diseases and infections were maintained for the facility for 1 of 2 (Resident #1) residents reviewed for parenteral fluids. The facility did not ensure Resident #1's central line (a tube that is inserted into a large vein in the neck, chest, groin, or arm to give fluids, blood, medications, or to do medical tests quickly) dressing was changed every seven days per the physician's order. This failure could place residents at risk for central line associated bloodstream infections. Findings Included: 1. [...]

Inspectors wroteBased on observation, interviews 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 kitchen sanitation in that: 1. Expired food was not disposed of. 2. Food was not labeled or dated. 3. Kitchen equipment was not kept free of carbon buildup. These deficient practices could place residents who received meals from the kitchen at risk for food borne illness.

Inspectors wroteBased on interviews and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 14 residents (Resident #33) reviewed for MDS assessment accuracy. The facility did not ensure Resident #33's quarterly MDS identified a medication as an anti-platelet instead of an anticoagulant. These failures could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care was provided with professional standards of practice for 1 of 2 resident reviewed for respiratory care and services. (Resident #142) The facility failed to administer oxygen at 3 liters via nasal cannula as prescribed by the physician for Resident #142. This failure could place residents who receive respiratory care at risk for developing respiratory complications.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, included the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of one medication room reviewed for medications storage (North Side Medication Room). The facility failed to remove an expired medication from the North Side Medication Room. These failures could place residents at risk for not receiving the therapeutic benefit of medications or adverse reactions to medications.

Inspectors wroteBased on interview and record review the facility failed to ensure the use of psychotropic medications was documented in the clinical record for 1 of 5 residents reviewed for unnecessary psychotropic drugs (Resident #30). The facility failed to adequately monitor Resident #30's side effects regarding her antidepressant medication. This failure could place residents at risk of receiving unnecessary psychotropic medications with possible medication side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.