Avir at Commons

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 6 (Resident #2) residents reviewed for pharmacy services. The facility failed to ensure Resident #2 was administered Enoxaparin Sodium (used to prevent and treat blood clots) Injection 40mg/.4ml on per physician order due to the medication being unavailable. The facility failed to ensure Resident #2 was administered Lisinopril-hydrochlorothiazide (used to treat high blood pressure) 20-25mg as prescribed due to the medication being unavailable These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to consult the resident's physician and notify when there was a need to alter treatment significantly for 1 of 6 residents (Resident #2) reviewed for notification of changes. The facility failed to contact the prescribing physician for Resident #2's Enoxaparin Sodium (used to prevent and treat blood clots) Injection Syringe 40mg/0.4ml to obtain a stop date or confirm or clarify administration duration. The facility failed to notify the MD Resident #2 missed a total of 21 doses of Enoxaparin Sodium Injection 40mg/0.4ml due to the medication being unavailable. The facility failed to notify the MD Resident #2 missed a total of 5 doses of Lisinopril-hydrochlorothiazide (used to treat high blood pressure) 20-25mg due to the medication being unavailable. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents received medication at time ordered by the physician for 2 of 3 residents (Resident #'s 1 and 2) reviewed for medication administration. The facility failed to ensure Resident #'s 1 and 2 received their medications timely according to the physician's orders on 5/13/2026. This failure could place residents at risk for adverse outcome, ineffective therapeutic response, and decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to distribute ice under sanitary conditions for 1 of 3 ice chests on hall 200. The facility failed to ensure ice was distributed under sanitary conditions on hall 200. These failures could place residents at risk of being served in unsanitary conditions and for waterborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have an effective infection control program to prevent the development and transmission of disease and infection for 1 of 2 residents reviewed for incontinent care/peri care (Resident #30). CNA A contaminated clean areas and did not thoroughly clean Resident #30 when providing incontinent care. This failure could place residents who required assistance with incontinent care at risk for discomfort, skin breakdown, cross contamination, and infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure they took steps to prevent further potential abuse or neglect while the investigation was in progress and they took appropriate corrective action after the alleged violation was verified for all alleged violations involving abuse, neglect, exploitation or mistreatment, including misappropriation of resident property for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 12 residents reviewed for abuse and/or neglect. 1. The facility failed to correct identified neglect identified in grievances filed on 02/02/26 related to Resident #1, Resident #3, and Resident #4 extra dummy call lights. 2. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents the right to be free from abuse and/or neglect for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 12 residents reviewed for abuse and/or neglect. 1. The facility failed to ensure Resident #1, Resident #3, and Resident #4 were provided with a call light to call for assistance when their call light was thrown on the floor and provided an extra one dummy that was not plugged into the call light system. 2. The facility failed to ensure Resident #2 was free from verbal abuse when CNA A told him Shut the [F-word] up and mind your business. These failures could place residents at risk of emotional harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 3 (Resident #1, Resident #3, and Resident #4) of 12 residents reviewed for abuse [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remains as free of accident hazards as is possible and each resident receives adequate supervision and assistance devices to prevent accidents for 1 (Resident #1) of 12 residents reviewed for quality of care. The facility failed to ensure CNA DD properly transferred Resident #1 on 02/10/26. This deficient practice could place residents at risk of injury.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to review and revise resident care plans based on changing goals, preferences, and in response to current interventions for 1 of 6 residents reviewed for care plans (Resident #1). The facility failed to ensure Resident #1's care plan was revised and updated to address safety, mental health, and nursing needs related to a history of exploitation and changes in discharge planning. This failure could place residents at risk for not having their safety, mental health, and goal setting needs addressed and communicated to the appropriate staff.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for 1 of 6 residents (Resident #2) reviewed for pharmacy services. The facility failed to ensure Medication Aides used available resources to administer 3 missed doses of eye drops to Resident #2 as ordered by the physician. This failure could place residents at risk of not receiving medications as ordered.

Inspectors wroteBased on observation, interview, and record review, the facility failed to immediately consult with the physician when a need to alter treatment significantly due to adverse consequences for 2 of 5 residents reviewed for resident rights. (Resident #1 and Resident #2) The facility failed to notify or consult with Residents #1 and #2's physician for the following: Resident #1 was readmitted to the facility on [DATE] with surgical incisionto the left groin, right groin, and left knee. He did not have treatment orders for these wounds. On 8/10/25 Resident #1's groin area was noted to have signs of infection. Resident #1 went to the hospital on 8/11/25 with a diagnosis of groin infection. Resident #2 was readmitted to the facility on [DATE] at 10:00 p.m. with a stage 4 to her sacrum. She did not have orders to treat the wound as of 6:00 p.m. on 8/13/25. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice for 2 of 5 residents reviewed for resident rights. (Resident #1 and Resident #2) The facility failed to notify or consult with Residents #1 and #2's physician for the following: Resident #1 was readmitted to the facility on [DATE] with surgical incisionto the left groin, right groin, and left knee. He did not have treatment orders for these wounds. On 8/10/25 Resident #1's groin area was noted to have signs of infection. Resident #2 was readmitted to the facility on [DATE] at 10:00 p.m. with a stage 4 to her sacrum. She did not have orders to treat the wound as of 6:00 p.m. on 8/13/25. An Immediate Jeopardy (IJ) situation was identified on 8/14/25 at 1:00 p.m. [...]

Inspectors wroteBased on observation, interview, and record, review the facility failed to provide care in a manner that ensured the residents dignity for 3 of 4 residents reviewed for dignity (Resident # 3, #4, and #5.) 1. The facility failed to provide Resident #3 with briefs that fit. 2. Resident #5 said she was anxious, and was afraid she would embarrass herself due to not having briefs that would fit.3. Resident #4 said she had briefs but that caused her discomfort because they were the wrong size.4. Residents and staff voiced concerns about not having briefs over the weekend on 8/9/25 and 8/10/25. These facility failure to provide residents with briefs that fit could place residents at risk at risk of anxiety, embarrassment and discomfort.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the kitchen. 1. The Dishwasher was not wearing a hairnet while working in the kitchen. 2. The Dishwasher was running dishes through the dish machine while the temperature gauge indicated the water was 106 °F. This failure could place residents who ate meals prepared in the kitchen at risk for food borne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were informed of how to file a grievance for 8 of 8 confidential interviews reviewed for grievances. Residents were not informed of their right to file a grievance during their stay in the facility. This failure could place residents at risk of a decreased quality of life, decreased awareness of their rights and decreased execution of their rights.

Inspectors wroteBased on interview and record review the facility failed to ensure accurate assessments were completed for 2 of 6 residents (Residents #3 and #41) reviewed for accuracy of assessments. The facility failed to ensure Residents #3 and #41's MDS assessments were accurately coded for Preadmission Screening and Resident Review (PASRR). These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were completed and accurately documented for 1 of 4 residents (Resident #59) reviewed for medical records accuracy. The facility failed to ensure the physician's orders for Resident #59 to received hemodialysis treatment related to renal failure, to be performed three days a week via left upper arm shunt at a dialysis care group facility. These failures could place residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

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 4 residents (Residents #42 and #76) reviewed for Enhanced Barrier Precautions. LVN E failed to cleanse the injection site prior to administering an insulin injection to Resident #76. LVN F failed to don appropriate PPE (a gown) prior to administering medications via Resident #42's feeding tube. These failures could place residents under their care at risk for the transmission of communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the residents' right to be free from verbal and physical abuse for 2 of 14 residents reviewed for abuse. (Resident #s 1 and 2) The facility failed to ensure Resident #1 was free from abuse when Resident #2 hit Resident #1 with an open hand to the back of the neck area on 04/08/24. The facility failed to ensure Resident #2 was free from abuse when Resident #1 intentionally rammed his wheelchair into Resident #2's wheelchair and then threatened to kill Resident #2. This failure could place the residents at risk for increased risk for abuse and neglect.

Inspectors wroteBased on interview and record review the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 1 of 14 residents (Resident #3) reviewed for quality of care. The facility failed to follow up with a cardiologist and neurologist referral for Resident #3 for 30 days. This failure could place residents at risk for not receiving appropriate care and treatment and or decline in their health.

Inspectors wroteBased on interview and record review, the facility failed to follow guidelines for mandatory submission of staffing information based on payroll data in a uniform format. Long-term care facilities must electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS, in that: The facility failed to submit staffing information to CMS for the 3rd quarter (April, May, June) of the fiscal year 2023. This failure could place residents at risk for personal needs not being identified and met, decreased quality of care, decline in health status, and decreased feelings of well-being within their living environment.

Inspectors wroteBased on an interview and record review, the facility failed to ensure that the facility's medical director or his/her designee attended the Quality Assessment and Assurance/Quality Assurance and Performance Improvement Committee meetings, for 1 of 1 facility, reviewed for QAA/QAPI. The facility failed to ensure the medical director attended their QAA and QAPI meetings for the months of December 2022, February 2023, July, August, September and October 2023. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented.