Avir at Converse

Inspectors wroteBased on observation record review and interview, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASRR) program for residents with newly evident or possible serious mental disorder for 3 of 13 Residents (Resident #67, #48 and #7) whose records were reviewed. The facility failed to refer Resident #67, #48 and #7 for Level I screening when diagnosed with a mental disorder. This deficient practice could affect residents with a mental diagnosis and can result in residents not receiving services as identified by PASRR.

Inspectors wroteBased on observation, interview and record review the facility failed to provide residents with a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 8 Residents (Resident #53 ) whose restrooms were observed for safety. The facility failed to ensure Resident #53 sink faucet was functional and did not spray water onto the floor. This deficient practice could prevent residents from using the sink in the restroom and could cause avoidable accidents.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 8 Residents (Resident #7) whose records were reviewed. The MDS Coordinator failed to include Resident #7's diagnosis of PTSD in his comprehensive care plan including care and services the facility would provide. This deficient practice could result in residents not receiving the care and services needed.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 (Resident #42) of 8 residents reviewed for care plan revisions. The facility failed to ensure Resident #42's care plan was revised to reflect resident no longer required the use of a foley catheter and resident being occasionally incontinent of urine. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview and record review the facility failed to provide food that accommodated resident preferences for 1 of 8 Residents (Resident #53) whose records were reviewed. The facility failed to provide Resident #53 the option to receive a regular diet (non-mechanically altered food) per her preference. This deficient practice could result in residents not having the freedom of making their own food choices.

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 observed for food and nutrition services. The facility failed to ensure dietary staff used facial hair restraints properly during meal preparation and dish washing. The facility failed to ensure the dietary staff used proper hand hygiene during plate preparation. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on the interview and record review, the facility failed to ensure, in accordance with accepted professional standards and practices, that medical records were accurately maintained for each resident, as documented for 1 of 4 residents (Resident #28) whose medical records were reviewed for accuracy. The facility failed to ensure that documentation on Resident #28's face sheet ccurately reflected the diagnosis of pain. This failure could place residents at risk of receiving improper care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were labeled and stored in accordance with currently accepted professional principles for 1 of 2 medication carts (Medication Cart 300/400) reviewed for storage of drugs and biologicals. The facility failed to ensure the medication cart for hall 300/400 did not have a vial of unlabeled insulin in it. These deficient practices could place residents at risk of receiving the wrong medication, misuse of medication or drug diversion.

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 and to help prevent the development and transmission of communicable disease and infection for 3 of 5 residents (Resident #1, Resident #2 and Resident #3) reviewed for infection control: 1. The facility failed to ensure Resident #1's pure wick tubing was not on the floor. 2. The facility failed to ensure Resident #2 had enhanced barrier precaution signage and supplies by Resident #2's door. 3. The facility failed to ensure Resident #3 had enhanced barrier precaution signage and supplies by Resident #3's door. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure all drugs and biologicals were stored in locked compartments under proper temperature controls and permit only authorized personnel to have access to the keys for 1 of 5 medication carts, (the 100-hall medication cart) reviewed for locked compartments. LVN A left the medication cart she was assigned, unlocked outside of a resident's room while she was in the room with the door shut. This deficient practice could place residents at risk for unauthorized persons having access to medications not approved for them.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 5 of 8 residents (Residents ##28, #25, #37, #31. and #38) reviewed for pharmacy services. 1. Resident #28's insulin flex pen (Humalog) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. 2. Resident #25's insulin (Lispro) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. It should have been discarded 28 days after opening. 3. Resident #37's insulin (Novolog) for diabetes had an open date of [DATE] found inside the 100/200-hall nursing cart on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 4 of 8 residents (Residents #37, #49, #31, and #54) reviewed for storage. 1. Resident #37's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. 2. Resident #49's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. 3. Resident #31's insulin Glargine (Lantus) for diabetes had no open date, found inside 100/200-hall nursing cart on [DATE]. Per the label of the insulin said, Discard 28 days after date opened. 4. [...]

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 11 of 23 (Housekeeper N, CMA F, CNA G, LVN H, Dietary Aide I, RN J, CNA K, CNA L, LVN M, LVN/MDS, Dietary Manager) employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured Housekeeper N, CMA F, CNA G, LVN H, Dietary Aide I, RN J, CNA K, CNA L, LVN M, LVN/MDS, Dietary Manager received required trainings annually. The facility failed to implement and maintain a training program that ensured Dietary Manager received required trainings upon hire. This failure 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 provide communications training for 4 of 23 employees (Housekeeper N, CMA F, CNA G, LVN H) reviewed for training, in that: The facility failed to ensure effective communication training was provided to Housekeeper N, CMA F, CNA G and LVN H annually. This failure 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 include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 5 of 23 employees (Housekeeper N, CNA G, Dietary Aide I, CMA F, RN J) employees reviewed for training requirements. The facility failed to ensure required QAPI trainings was provided to Housekeeper N, CNA G, Dietary Aide I, CMA F, and RN J annually. This failure 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 provide mandatory ethics training for 7 of 23 employees (Housekeeper N, CNA G, RN J, CNA K, CNA L, LVN M, LVN/MDS) employees reviewed for training, in that: The facility failed to ensure ethics training was provided to Housekeeper N, CNA G, RN J, CNA K, CNA L, LVN M, and LVN/MDS annually. This failure 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 CNA received the required minimum 12 hours annual in-service for 3 of 6 CNAs (CNA G, CNA K, CNA L) reviewed for training. The facility failed to provide the required 12 hours of annual training to CNA G, CNA K, CNA L. This failure 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 provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71 for 2 of 28 (Dietary Aide I and Dietary Manager) employees reviewed for training, in that: The facility failed to ensure behavioral health training was provided to Dietary Aide I annually. The facility failed to ensure behavioral health training was provided to Dietary Manager upon hire. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

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 8 residents (Resident #18) who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #18. This failure could affect any resident and keep them from calling for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to transmit encoded, accurate, and complete MDS data to the CMS System for 1 of 16 residents (Resident #6) reviewed for MDS transmission. Resident #6's discharge MDS assessment was not completed and transmitted within 14 days of completion. This failure could place residents at risk of not having assessments completed and submitted in a timely manner as required.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 of 20 residents (Resident #1) reviewed for assessments: Resident #1's quarterly MDS, dated [DATE], identified the resident had anticoagulant (blood thinner). However, Resident #1 did not have anticoagulant. This failure could place residents at risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 20 residents (Resident #58) reviewed for care plans. The facility failed to ensure Resident #58's care plan reflected his smoking status and included a care plan regarding how to take care of the resident's smoking. This failure could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bowel and bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #4) reviewed for incontinence care. When CNA-A was providing incontinent care to Resident #4 on 04/03/2025, CNA-A did not separate the resident's labia and did not clean the base of her labia. This failure could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 of 2 (Resident #20) reviewed for respiratory care. Resident #20's oxygen nasal cannula was not covered in a plastic bag when it was not used on 04/01/2025. This failure could affect residents with oxygen therapy and could lead them to lack of care including possible infection by not following infection control.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #3) of 3 residents reviewed, in that: Resident #'3s personal refrigerator located in her room was observed on 04/01/2025. There was a small plastic cup inside the refrigerator, with no date and no label on the plastic cup. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #24) of 7 residents reviewed for infection control practices. MA C did not clean the blood pressure cuff between use and prior to taking Resident #24's blood pressure. These deficient practice could place residents at risk for cross contamination and infections.

Inspectors wroteBased on interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 1 of 8 residents (Resident #7) reviewed for accuracy of medical records in that: 1. a. The facility failed to have an accurate fall risk assessment for Resident #7 when the resident had 4 falls between February and August 2024 and the assessment on 08/19/2024 indicated Resident#7 was at low risk. b. The facility failed to accurately document neuro checks for Resident #7 for every 30 min Neurological checks times 3 after the fall on 09/17/2024. This deficient practice could place residents at risk for errors in care and treatment.

Inspectors wroteBased on interview, record review, and observation, the facility failed to ensure residents have a right to personal privacy for 1 of 2 resident (Resident #6) reviewed for privacy, in that: CNA A and CNA B did not close Resident #6's privacy curtain while providing incontinent care on 3/27/25. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment, and describes services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 4 residents (Resident #1) reviewed for care plans. The facility failed to ensure a care plan was developed to address Resident #1's high risk for falls which was identified in his admission fall risk assessment, and failed to include a care plan regarding how to prevent falls. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 1 resident (Resident #1) reviewed for incontinence care, in that: Resident #1 was provided with inadequate incontinence care by CNA A and CNA B. This failure could place residents who required incontinence care at risk for the development of new or worsening urinary tract infections.

Inspectors wroteBased on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 6 residents (Resident #1) whose records were reviewed for code status. The facility failed to ensure nursing staff followed emergency protocol and failed to ensure staff provided Resident #1, who had a Full Code in place, CPR, after the resident was found unresponsive with no pulse or respirations, according to professional standards of practice. On [DATE] at 4:51 p.m., and Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interviews and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 of 6 residents (Resident #1) reviewed for accuracy of medical records. The facility failed to ensure Resident #1 had physician orders for crushed medications on the electronic medication administration record (EMAR ). This deficient practice could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment.

Inspectors wroteBased on observation, record review, and interviews, the facility failed to provide adequate supervision, for 1 of 4 residents (Resident #3) reviewed for accidents, hazards, and supervision. Resident #3 walked out of the facility through an alarming door without staff responding. This deficient practice placed residents at risk for being unsupervised, accidents, and injury. This failure resulted in the identification of an Immediate Jeopardy (IJ) on 4/8/2024 at 2:05 PM. While the immediacy was removed on 4/9/2024, the facility remained out of compliance at a severity level of potential for more than minimal harm that was not an Immediate Jeopardy and a scope of isolated due to the facility's need to monitor the implementation of the plan of removal.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the confidentiality of personal health care information for 1 of 4 residents (Resident #1) reviewed for confidentiality of records during the survey in that: The facility failed to ensure LVN A locked and closed the laptop during the medication pass exposing Resident #1's personal information. This failure could affect residents by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on interviews and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 1 (Resident #3) residents reviewed for assessments. Resident #3 was discharged and did not have a discharge MDS in the electronic record. This could affect all resident discharged and could result in residents missing services.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys, for 1 of 2 medication cart s (Medication Cart 4), reviewed for security, in that, A medication cart was unattended and unlocked. This failure placed residents at risk for harm by misappropriation of property and not receiving the therapeutic effects of their medications.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents had the right to request, refuse, and/or discontinue treatment, to participate in experimental research, and to formulate an advance directive for 1(Resident #69) of 24 residents reviewed for advanced directives. The facility failed to honor the rights of Resident #69's wishes to die a dignified death by failing to honor a signed OOH DNR order on [DATE] at 9:30 AM when Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:55 p.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to provide basic life support , including CPR, to a resident requiring such emergency care prior to the arrival of medical personnel and subject to related physician orders and the resident's advanced directives for 1(Resident #69) of 24 residents reviewed for advanced directives. The facility failed to provide emergency care subject to physician orders and the resident's advanced directives when Resident #69 was readmitted to the facility. On [DATE] at 09:30 AM Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes when he had an OOH DNR. An IJ was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 5:55 p.m. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objective and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Residents #35, #36, #44 and #56) of 16 residents reviewed for care plans. 1. Resident #35's comprehensive care plan did not address she was contracted in her hands. 2. Resident #36's comprehensive care plan did not address all areas affected by the resident's hemiplegia. 3. Resident #44's compression stockings were not reflected in the resident's care plan. 4. Resident #56's Renal Diet was not reflected in his care plan. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. 1. [NAME] P and DA S did not properly wear hair restraints in a way that covered all their hair. 2. DA Q and DA R were wearing jewelry while preparing food in the kitchen. 3. The walk-in freezer contained: a. A clear, plastic bag of food that was knotted at the top, contents unknown, without a label or date. b. There was a single serve ice cream cup on the floor of the walk-in freezer. 4. Excessive amount of debris and food scraps on the floor between meal serves. 5. Wall behind the clean dish storage was dirty. These failures could affect the residents who received meals from the kitchen and place them at risk for foodborne illness.

Inspectors wroteObservation, interview and record review revealed the facility failed to ensure the residents had a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely for 1 of 4 hallways (100) and in 2 of 2 shower rooms (men and women's) observed for environmental conditions. 1. The facility failed to ensure the floor on 100 hall was a flat and even surface. 2. The facility failed to ensure the men and women's shower stall had an even floor surface and the water drained while residents were showered. These deficient practices could affect any resident and could contribute to trips, falls and unsatisfactory shower room condition for residents.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure alleged violations involving abuse, neglect, exploitationexploitation, or mistreatment, including injuries, of unknown source and misappropriation of resident property are reported immediately, but not later than 2 hours after the allegation was reported for 1 (Resident #69) of 4 residents reviewed for reporting of alleged violations. The facility failed to report that Resident #69's wishes to die a dignified death was not honored and that nursing staff failed to honor a signed OOH DNR order on [DATE] at 09:30 AM when Resident #69 was found unresponsive without a pulse and had a full code initiated to include CPR for approximately 25 minutes. This facility failure affects residents involved in incidents and could result in alleged violations not being investigated in a timely and proper manner.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 1 resident (Resident #35) of 24 residents reviewed for MDS assessments. Resident #35's MDS assessment did not accurately reflect she had limitations on her upper extremities and she was on continuous oxygen therapy. This deficient practice could result in missed or inaccurate care.

Inspectors wroteBased on interview and record review the facility failed to refer all residents with possible serious mental disorder or a related condition for level II resident review upon a significant change in status assessment for 2 of 6 Residents (Resident #9 and Resident #43) whose records were reviewed for mental disorders. The facility failed to refer Resident #9 for a PASARR evaluation based on mental disorder diagnoses including Major Depressive Disorder and Psychosis. The facility failed to refer Resident #43 for a PASARR evaluation based on mental disorder diagnoses including Major Depressive Disorder and Psychosis. This deficient practice could affect residents with a mental illness and contribute to a delay in services needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment including both the comprehensive and quarterly review assessments for 1 of 24 (Resident #35) residents reviewed for care plan revisions. The facility failed to ensure Resident #35's care plan was updated to reflect the resident was on oxygen therapy. This deficient practice could place residents at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 1 of 3 Residents (Resident #14) reviewed for accidents and hazards. CNA X did not widen the base of the mechanical lift while transferring Resident #14 from bed to his wheelchair on 2/23/24. This deficient practice could placed residents transferred via mechanical lift at risk of falls which could result in injury and hospitalization.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needs respiratory care is provided such care, consistent with professional standards of practice and the comprehensive person-centered care plan for 1 of 1 Resident (Resident #38) whose records were reviewed for oxygen care. The facility failed to ensure Resident #38's oxygen concentrator was cleaned and the filter was not covered in lint. This deficient practice could affect residents residents on oxygen at risk of decreased efficiency of the concentrator and infection.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain medical records on each resident that are-accurately documented for 1 (Resident #44) of 24 residents reviewed for accurate medical records in that: LVN F initialed off on Resident #44's MAR that the resident's compression stockings were applied on 02/22/2024, when they were not. This deficient practice could affect residents who have medical records and could result in misinformation about professional care provided.

Inspectors wroteBased on observation, 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 (Resident #44) of 5 residents reviewed for infection control in that: Resident #44's ventilator mask and oxygen nasal cannula tubing were left unbagged for 2 days when not in use. This facility failure affects residents on oxygen therapy and could result in upper respiratory infections.