Avir at Courtyard

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents had the right to be informed of, and participate in, his or her treatment for 1 (Resident #1) of 5 residents reviewed for resident rights.- The facility failed to notify Resident #1's Responsible Party before initiating Risperidone on 01/31/26. This failure could place residents at risk of adverse reactions.

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate PASRR for 2 of 6 residents (Residents #1 and Resident #56) reviewed for PASRR Level 1 screenings. The facility failed to verify the accuracy of the negative PASRR Level 1 Screening for Resident # 1 and Resident #56, who had diagnoses of mental illness. This failure could affect residents with mental illness placing them at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs. Findings Included:Resident #1 Record review of Resident #1's face sheet dated 09/10/2025 revealed a [AGE] year-old male admitted to the facility on [DATE] with diagnoses which included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received an accurate assessment reflecting the resident's status for 1 of 16 residents reviewed for assessment accuracy. (Resident #7) ---Resident #7's Dialysis was not coded on the MDS This failure placed residents at risk of having inaccurate assessments and receiving improper care and services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests. The facility failed to ensure the facility was free from pests/insects in multiple areas including one of one kitchen and one of one conference room. This failure could place residents at risk for insect borne illnesses, and cause residents to live in an uncomfortable environment free of pests.

Inspectors wroteBased on interviews and record review, the facility failed to properly discharge and include all other necessary information, including a copy of the resident's discharge summary, and any other documentation, to ensure a safe and effective transition of care for 1 of 5 residents (Resident #61) reviewed for transfer and discharge requirements. The facility failed to provide all necessary information and/or documentation for a safe and effective transition to the resident, responsible party (RP), ombudsman, or the home health agency upon discharge for Resident #61. This failure could place residents at risk of not receiving the necessary care and services when discharged to meet their physical and psychological needs.

Inspectors wroteBased on interviews and record review the facility failed to establish and follow a written policy on permitting residents to return to the facility after they were hospitalized for 1 of 5 residents (Resident #61) reviewed for return to the facility. - The facility failed to readmit Resident #61 after sending the resident to the hospital and refusing to readmit him back to the facility. -The facility failed to provide evidence they notified Resident #61's Responsible Party or the physician about his discharge to the hospital. These failures could place residents, who transfer to the hospital, at risk of being denied readmission to the facility and could result in a decreased quality of life and resident rights violations.

Inspectors wroteBased on observations, interviews, and record review the facility failed to conduct initial and periodical and comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 2 (Residents #46, #113) of 16 residents reviewed for accuracy of resident assessments. Residents #46 and #113 were not assessed accurately on their annual comprehensive MDS assessments. These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide appropriate care, treatment, and services to maintain or improve his or her ability to carry out the ADLs for 1 of 16 residents (Resident #23) reviewed for ADL care. The facility failed to assist and provide Resident #23 nail care. This failure could lead to self-injuries and diminish health conditions. Resident # 23 Record review of Resident #23's admission Record dated 08/14/24 revealed he was admitted to the facility on [DATE] and readmitted on [DATE]. His diagnoses included cerebrovascular diseases (a condition that affect blood flow and blood vessel in the brain), blindness, essential hypertension, osteoarthritis of knee (deterioration of the knee joints), and depression. Record review of Resident #23's Annual MDS dated [DATE] revealed he was cognitively intact, with a BIMs score of 14 out of 15. [...]

Inspectors wroteBased on observations and interview, the facility failed to ensure that drugs and biologicals used in the facility were stored and labeled in accordance with currently accepted professional principles reviewed for medications, 1 of 2 medication aide carts, and 2 out 3 of nurse's carts. Station 1 nurse medication cart A had a blister packet of Lorazepam, 0.5mg for a discharged Resident control medication, was still in the medication cart in station 1 nurse's cart. Station 1 medication aide cart B had 6 blister packets of medications: Lipitor 40 mg, sertraline HCL 25 mg, LevETIRAcetarn 75 mg, metoprolol tartrate 25mg, baclofen 10mg, gabapentin 100mg, Sertraline HCL 25 mg was left in the cart, and the resident was discharged from the facility on [DATE]. fluticasone propionate nasal spray that was open and not dated. Station 2 nurse medication cart B had opened and undated: [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to to provide appropriate dental care for 1 (Residents #113) of 16 residents reviewed for dental. The facility failed to provide proper dental care and assure her denture concerns were addressed with Resident #113. These failures could place residents at risk of not receiving the care needed to maintain their highest, practicable, physical, social, and psychosocial level of well-being.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety. The facility failed to ensure that the deep fryer grease was changed regularly and kept clean. The facility failed to ensure that the dishwashing area was free of stagnant water and the walls were clean. This failure placed residents at risk for foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to prevent the development and transmission of infection for 2 of 6 residents (Housekeeper C, and CNA L) observed for infection control. 1. The facility failed to ensure Housekeeper C followed proper infection control and PPE while pushing a dirty trash can on section 1 hallway. 2. The facility failed to ensure CNA L followed proper infection control and hand washing procedure during incontinent care for Resident #25. These failures could place residents at risk for infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all mechanical, electrical, and patient care equipment was in safe operating condition for 1 of 6 residents (Resident #25) reviewed for safe operating patient care equipment. The facility failed to maintain Resident #25's electric bed remote in safe operating condition. This failure could put residents in the facility at risk of injury.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 43 residents (CR #229) reviewed for free of accidents, hazards, supervision, and devices. -The facility failed to develop any interventions following CR #229's fall on [DATE]. CR #229 fell again on [DATE], suffered a traumatic head injury and died as a result of his injuries. On [DATE] at 3:09 p.m. an Immediate Jeopardy (IJ) was identified. While the IJ was lowered on [DATE] at 2:36 p.m., the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal (POR). [...]

Inspectors wroteBased on 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 1 of 7 residents (CR #229) reviewed for reporting of alleged violations. [...]

Inspectors wroteBased on, interview, and record review, the facility failed to ensure allegations of abuse and neglect were thoroughly investigated and reported results of the investigation to the state agency within 5 working days of the incident for 1 of 7 residents (CR #229) reviewed for investigate, prevent, and correct alleged violation, in that: The facility did not complete an investigation report regarding CR #229. This failure placed residents at risk of injury, harm, and leaving him susceptible to repeated abuse/neglect and injury of unknown origin.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident's assessment was completed within 7 and 14 days, and electronically transmit encoded, accurate, and complete MDS data to the CMS System for a subset of items upon a resident's transfer, reentry, discharge, and death for 1 of 3 discharged residents (CR #33) reviewed for encoding and transmitting resident assessments, in that: - The Facility failed to complete and transmit a discharge MDS for CR #33. This failure could place discharged residents at risk of not having a proper discharge and not receiving services post discharge.

Inspectors wroteBased on interview and record review, the facility failed to develop a person-centered comprehensive care plan for each resident, consistent with the resident rights for 1 of 5 residents (Resident #70) reviewed for develop and implement comprehensive care plan, in that: - The facility failed to address the smoking status in Resident #70's care plan. This failure could place residents at risk for receiving decreased quality of care and or not receiving the appropriate required care and services to meet their individual needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure one of fifteen residents (Resident #27 ) who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding, in that: -The facility did not have the supplies available to replace the Gastrostomy Tube for Resident #27 for at least 5 days and used an indwelling urinary Foley catheter for at least 5 days, instead of an actual gastrostomy tube. -The facility did not have appropriate physician orders for Resident #27's medications to be administered through the temporary indwelling urinary Foley catheter, while it was being used as a gastrostomy tube. The failure could place residents with gastrostomy tubes at risk for developing significant complications, including infections, aspiration, hospitalizations, or death.