Avir at Elkhart

Inspectors wroteBased on interviews and record review, the facility failed to consider the views of a resident or family group and act promptly upon the grievances and recommendations of such groups concerning issues of resident care and life in the facility for 15 out of 15 anonymous residents during a confidential meeting who were reviewed for resident rights. The facility failed to ensure the resident council grievances were promptly resolved. This failure could place residents at risk for a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for residents for 4 of 8 residents (Resident #2, Resident #33, Resident #40, and Resident #44) observed for resident environment.1. The facility failed to ensure the room of Resident #2 and Resident #44 did not have a baseboard that was detached from the wall from 6/1/2026 to 6/3/2026. 2. The facility failed to ensure hot water was available in resident bathroom for Resident #33 on 6/1/26 and 6/2/26. 3. The facility failed to ensure the room of Resident #40 did not have a hole in the wall behind the door from 6/1/2026 to 6/3/2026. These failures could place residents at risk for an unsanitary and uncomfortable environment.

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, mental and psychosocial needs that are identified in the comprehensive assessments for 6 of 12 residents reviewed for care plans. (Resident #23, Resident #24, Resident #26, Resident #31, Resident #33, and Resident #53,).1. The facility failed to include in Resident #23's care plan activities of daily living and transfer status. 2. The facility failed to include in Resident #24's care plan activities of daily living and transfer status. 3. The facility failed to include in Resident #26's care plan activities of daily living, urinary and bowel incontinence and his PASRR status. 4. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the residents' status for 1 of 6 residents reviewed for assessments. (Resident #15) The facility failed to ensure Resident #15's quarterly MDS assessment, dated 3/03/2026, was coded correctly. This failure could place residents at risk of not having individual needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing for 1 of 6 residents (Resident #6) reviewed for pressure ulcers. The facility failed to provide wound care for a pressure ulcer to his left heel for Resident #6 for 10 of 31 days in May of 2026 which could have caused pressure ulcers to deteriorate. The facility failed to ensure a wound care treatment order was in place for Resident #6 for 10 days between the dates of 5/25/26 and 6/3/26. This failure could place residents with pressure ulcers at risk for wound deterioration and decline in existing pressure ulcers.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 3 of 10 residents reviewed for quality of care. (Resident #23, Resident #24, and Resident #31)The facility failed to remove worn and damaged mechanical lift slings from service for Resident's #23, #24, and #31. This failure could result in a loss of quality of life due to injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated that it was not possible or the resident preferences indicated otherwise for 1 of 6 residents (Resident #7) reviewed for nutrition status. The facility failed to follow facility policy and dietary recommendations for Resident #7. Resident # 7 lost 29 lbs. from 3/26/2026 to 05/05/2026 which was a significant weight loss of 20.7%. These failures could place residents at risk for loss of weight and inadequate nutrition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all medications were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts (Nurse Cart) reviewed for medication storage. The facility failed to ensure injectable medications were labeled with an open and use by date on 6/3/26. This failure could put residents at risk for adverse reactions to medications and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 2 of 12 residents (Residents #3 and #33) reviewed for call lights. The facility failed to ensure Resident #3 had a call light in the bathroom that was functional on 06/01/2026 and 06/02/2026. The facility failed to ensure Resident #33's bathroom had a call light pull cord on 6/1/26. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own established smoking policy for 1 of 2 smoking areas. The facility failed to keep paper and plastic trash out of the designated ashtrays and fire can on 6/02/2026. This failure could place residents at risk for injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide residents a safe, clean, comfortable and homelike environment for 1 of 5 showers (Shower A) and 1 of 5 residents (Resident #1) reviewed for environment. The facility failed to ensure when a torn shower curtain and broken shower head holders were observed in a shared facility shower. This failure could place all residents at risk of diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident, as determined by resident assessments and individual plans of care and considering the number, acuity and diagnoses of the facility's resident population in accordance with the facility assessment for 6 of 6 resident hallways (Halls #1, #2, #3, #4, #5, and #6) reviewed for sufficient staffing in that:The facility failed to ensure sufficient nursing staff when multiple residents and family members reported slow or no call light response. The facility failed to provide an additional support nurse to assist the charge nurse on 8/4/25, 8/5/25, and 8/6/25. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to store and label foods in accordance with professional standards. 2. The facility failed to ensure there were no gaps under the air conditioning unit beside the handwashing sink. 3. The facility failed to maintain clean air vents on the air conditioner located near the clean dish station. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and/or transmission-based infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food prepared in a form designed to meet individual needs for 4 of 4 (Resident #6, Resident #28, Resident #40, and Resident #41) residents reviewed for puree diets. The facility failed to prepare the pureed diet to the consistency required for Residents #6, Resident #28, Resident #40, and Resident #41. This failure could place residents who received pureed meat and vegetables at risk of not having nutritional needs met by consuming foods that could cause choking and decreased meal intakes.

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 1 of 6 (Resident #43) reviewed for pharmacy services. The facility failed to provide Resident #43's naproxen (anti-inflammatory medication) 250 mg tablet ordered to be given two times a day from 1/4/2025-4/8/2025 per physician's orders. This failure could place residents who received administered medications at risk of not receiving the intended therapeutic benefit of their medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 3 resident's (Resident #2) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure a plastic bag of sliced cheese and sandwich meat was labeled and dated in a personal refrigerator on 4/7/2025 and 4/8/2025 for Resident #2. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. Two of six gas stove burners (rear middle and font middle) did not light automatically, when the knob was turned, the pilot light on the burners would not light and both burners had black hard carbon buildup from spilled foods. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food.

Inspectors wroteBased on observation, interview, and record review the facility failed to be adequately equipped to allow residents to call for staff through a communication system which relayed the call directly to a staff member or to a centralized staff work area from toilet and bathing facilities for 2 of 9 residents (Residents #4 and #6) reviewed for call lights. The facility failed to ensure Residents #4 and #6's bathrooms had a call light pull cord on 04/07/2025. This failure could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to follow established policy regarding smoking areas, and smoking safety for the 1 of 2 (secured unit smoking area) smoking areas reviewed. The facility failed to ensure the paper trash and cigarette butts were disposed of separately in the ashtrays and red fire can on 04/07/25. This failure could place residents who smoke at risk of physical harm and lead to an unsafe smoking environment.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 11 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free of abuse from HSK-A. On 06/25/24 HSK A yelled and cursed at Resident #1. The noncompliance was determined to be PNC. The noncompliance began on 06/25/24 and ended on 06/26/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of verbal abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to store and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. DA C failed to follow the cleaning and sanitizing requirements for equipment when she dried wet plates from the dishwasher on 02/26/2024. 2. The facility failed to store foods in accordance with professional standards. 3. The facility failed to date opened items in the refrigerator. These failures could place residents who ate the food from the kitchen at risk for food-borne illness and/or transmission-based infections.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS (Centers for Medicare & Medicaid Services) 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 for 1 of 4 quarters (Fiscal year 2023 for the fourth quarter July 1, 2023 to September 30, 2023) reviewed for administration. The facility failed to submit data for the fourth quarter of the fiscal year from July 1, 2023, to September 30, 2023, to CMS This failure could place residents at risk for personal needs not being identified and met.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain all essential equipment in safe operating condition, for 1 of 1 stove in the kitchen reviewed for food service in that: The facility did not ensure the gas stove was in working order. Two of six gas stove burners (rear middle and font middle) did not light automatically, when the knob was turned, the pilot light on the burners would not stay lit and both burners had carbon buildup. This failure could place residents who eat out of the kitchen at risk for injury and under cooked food.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were offered sufficient fluid intake to maintain proper hydration and health for 7 of 14 residents (Residents #6, #7, #9, #13, #30, #33, and #41) reviewed for hydration. The facility failed to ensure Resident #6, Resident #7, Resident #9, Resident #13, Resident #30, Resident #33, and Resident #41 received adequate fluids during the 6am to 2pm shift on 2/26/24. This failure could place residents at risk for dehydration, electrolyte imbalance, and infections.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 16 residents (Resident #36) reviewed for assessments in that: The facility failed to reassess Resident #36 following a hospice admission (specific care for the sick or terminally ill) on 02/02/2024. This failure could place residents at risk for not having their individual needs met due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards and each resident received adequate supervision as is possible for 1 of 1 resident (Resident #5) reviewed for accidents and hazards. The facility failed to ensure that Resident #5 did not have a rechargeable vape device at bedside. The facility failed to supervise Resident #5 while using a rechargeable vape device that was affixed to a device clamped to her bedside table designed to hold it next to her face. The facility failed to ensure that Resident #5 did not use vaping device with door open, exposing other residents to secondhand exposure. This failure could place residents that vape at risk of nicotine overdose and vape related injuries.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who need respiratory care are provided such care, consistent with professional standards of practice for 1 of 9 residents (Resident #21) reviewed for oxygen usage. The facility failed to ensure Resident #21's oxygen tubing was stored properly when not in use and discarded when contamination occurred. This deficient practice could place residents at risk of respiratory infections.

Inspectors wroteBased on interview and record review the facility failed to establish a system of records of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation and follow a policy to provide pharmacy services in accordance with State and Federal laws or rules of the Drug Enforcement Administration for 2 of 12 months (July 2023 and September 2023) reviewed for pharmacy services. The facility failed to properly inventory drugs at time of disposal on 7/7/2023 and 9/5/2023. This failure could put residents at risk for misappropriation and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to be equipped to allow residents to call for staff through a communication system which relays the call directly to a centralized staff work area for 2 of 16 residents (Resident #24 and Resident # 36) reviewed for call lights. The facility failed to ensure Resident #24's emergency call button in the bathroom had a pull cord. The facility failed to ensure Resident #36's call light was within reach while in bed. These failures could place residents at risk of injury, pain, hospitalization, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to follow their own established vaping policy for 1 of 1 resident (Resident #5) reviewed for vaping. 1. The facility failed to follow the policy on vaping by allowing Resident #5 to have a rechargeable vape device at bedside. 2. The facility failed to follow the policy on vaping by failing to supervise Resident #5 while using a rechargeable vape device that was affixed to a device clamped to her bedside table designed to hold it next to her face. 3. The facility failed to follow the policy on vaping by not ensuring that Resident #5 did not use vaping device with door open, exposing other residents to secondhand exposure. These failures could place residents at risk of unsafe vaping and injury.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 4 of 30 days (9/24/23, 9/30/23, 10/1/23, and 10/8/23) reviewed. (September 2023 and October 2023) The facility did not have RN coverage for 2 days in September 2023. The facility did not have RN coverage for 2 days in October 2023. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.