Avir at Emerald Hills

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that at the time each resident was admitted , the facility had physician orders for the resident's immediate care for 1 resident (Resident #1) of 3 residents reviewed for admission orders. The facility failed to ensure that Resident #1, who was admitted on [DATE] with a suprapubic catheter (medical device inserted in the bladder to help drain urine), had physician orders in place for catheter care. This failure could place residents at risk of not receiving essential care upon admission.

Inspectors wroteBased on interview and record review, the facility failed to ensure a Registered Nurse was on duty in the facility for a minimum of eight consecutive hours a day, seven days a week, for 1 of 4 quarters, (Quarter 1), reviewed for RN coverage. 1. The facility failed to have 8 consecutive hours of RN coverage for 7 of 31 days in October 2025.2. The facility failed to have 8 consecutive hours of RN coverage for 1 of 30 days in November 2025. This failure could affect the residents by placing them at risk for not having their nursing and medical needs met and receiving improper care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that, a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal care for 2 of 4 residents (Residents #84 and #2) reviewed for ADL care. 1. The facility failed to ensure personal hygiene and grooming, to include hair care and oral care, was provided to Resident #84. 2. The facility failed to ensure nail care, to include trimming and cleaning, was provided to Resident #2. These failures put residents at risk for not receiving the care they require and poor quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services for 3 of 3 residents (Resident #65, Resident # 60 and Resident #7) reviewed for urinary catheters.1. Resident #60's catheter bag was observed to be hanging on the back of his wheelchair and was so full it was dragging the ground on 06/16/26.2. Resident #65's catheter bag was observed to be hanging from his bed and was touching the floor on 06/17/26.3. Resident #7's catheter bag was observed hanging from her bed and was touching the ground on 06/18/26. These failures could place residents who use catheters at risk of infection or injury.

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 in one of one kitchen in that:1. One pack of opened lunch meat was undated and unlabeled in refrigerator #2.2. One pack of opened chicken patties was undated and unlabeled in freezer #1. This failure could affect residents who receive meals from the kitchen in that they could be at risk of contracting food borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to promptly notify the ordering physician of results that fall outside of clinical reference ranges in accordance with facility policies and procedures for 1 of 3 residents (Resident #1) reviewed diagnostic services. LVN A failed to ensure x-ray results for Resident #1's swollen left wrist was reported to the physician when they were available in the lab portal at 11:00 PM on 04/07/26. The facility did not check the lab portal for Resident #1's x-ray results until the morning of 04/08/26 around 6AM when LVN B arrived to work, and the x-ray report revealed Resident #1 had a fractured left wrist, which had resulted from a fall. This failure could affect residents by placing them at risk for untreated illnesses, and delays in necessary care and deterioration in condition.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 2 residents (Residents #1) reviewed for respiratory care. The facility failed to ensure there was a physician order for Resident #1's oxygen therapy when the resident admitted to the facility on [DATE]. This failure could place residents at risk for respiratory infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals for 1 of 6 residents (Resident #3) reviewed for pharmaceutical services. MA A failed to supervise Resident #3 after he left the resident's medications in her room during morning medication administration on 12/09/25. This failure could place the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on interview, observation, and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 6 residents (Resident #4) reviewed for medication administration. The facility failed to administer Resident #4's Keppra/levetiracetam (an anti-epileptic drug used to treat seizures) as prescribed. This failure could place residents at risk of inadequate therapeutic outcomes, increased adverse side effects, and decline in health.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention 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 6 residents (Residents #1 and #2) reviewed for infection control. MA A failed to sanitize a re-useable blood pressure cuff between uses on Resident #1 and Resident #2. This failure could place the residents at risk of exposure to infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement written policies and procedures that prohibited and prevented abuse, neglect, and exploitation of residents and misappropriation of resident property for one of one resident (Resident #1) reviewed for abuse, neglect, and exploitation. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received adequate supervision and assistive devices to prevent accidents for 1 resident of 8 residents (Resident #1) reviewed for assistive devices and supervision. The facility failed to ensure Resident #1 received adequate supervision and care in accordance with professional standards when the resident was left attended on the toilet resulting in her falling and sustaining fractures to the Femur and left Hip. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for 1 of 5 residents (Resident #10) reviewed for physical environment. The facility staff failed to remove all kitchen coffee from Resident #10's room cups located on the toilet after resident use. The facility staff failed to discard used disposable gloves, and a plastic cup after use. The facility staff failed to ensure Resident #10's incontinent briefs and dirty clothing were properly stored and discarded. The facility staff failed to ensure Resident #10's mattress properly fit her bed and not move from the position. These failures could place residents at risk for a diminished quality of life, cross contamination, falls, injuries, and unsanitary environment.

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, were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury to the administrator of the facility and to other officials including to the State Agency in accordance with State law through established procedures, for one of one resident (Resident #1) reviewed for abuse, neglect and exploitation . The facility failed to report to the state agency when Resident #1 was left unattended in the bathroom and fell sustaining injuries of a fractured femur and fractured left hip. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents' had the right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive for 2 of 8 residents (Resident #3 and resident #73) reviewed for advanced directives. The facility failed to ensure Resident #3's and Resident #73's Out-of-Hospital Do Not Resuscitate (OOH-DNR) documents had the Physician's Statements signed by the physician and included the physician's license number, rendering the document invalid. This failure could place residents at-risk of having their end of life wishes dishonored, and of having CPR performed against their wishes.

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 for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to seal opened items in plastic bags in the dry storage pantry, refrigerator, and freezer areas on 04/15/25. 2. The facility failed to ensure expired items in the dry storage pantry, refrigerator and freezer areas were removed on 04/15/25. 3. The facility failed to ensure the dented cans in the dry storage area were removed from the shelf on 04/15/25. These deficient practices could place residents at risk for cross contamination and other food-borne illnesses . Findings Include: [...]

Inspectors wroteBased on observations, interviews and record reviews, 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 2 (Residents #1 and #2) of 5 residents reviewed for infection control, in that: PTA B failed to follow droplet precautions for Resident #1 by not donning an N95 mask respirator or eye protection prior to entering the room to perform therapy services. CNA C failed to follow droplet precautions for Resident #2 by not donning eye protection prior to entering the room to provide care services. These failures could affect residents and place them at risk for cross contamination and infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents had physician orders for the resident's immediate care for 1(Resident #17) of 5 residents reviewed for physician orders in that LVN-A failed to update the physician orders for Resident #17, to reflect changes in the physician's plan of care. This failure could place the resident at risk of not receiving the care intended by the physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident status for 1 of 12 residents (Resident #74) reviewed for MDS assessment accuracy in that: Resident #74's quarterly MDS assessment dated [DATE] was coded incorrectly for insulin injections when he was not receiving insulin. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop a comprehensive care plan for 1 (Resident #17) of 5 residents reviewed for comprehensive care plans. The MDS Coordinator failed to care plan to address Resident #17's orthopedic braces. This failure could result in the resident not receiving appropriate care for her fractures.

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 two of four staff (Dietary [NAME] and Dietary Aide) reviewed for kitchen sanitation in that: The Dietary [NAME] and Dietary Aide failed to properly wear a beard restraint while in the food preparation area. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview, and record review, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, consistent with the resident's comprehensive assessment and plan of care for 1 (Residents #1) of 4 residents reviewed for quality of life. The facility did not ensure Residents #1 received a shower upon and after being admitted on [DATE]. Resident was not showered until 12/17/23. Resident #1 was not showered on his scheduled day of 12/15/23. This deficient practice had the potential to affect residents by placing them at an increased risk of poor self-esteem, infections, socialization, and a poor quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to provide a sanitary environment for 1 (Residents #1) of 4 residents reviewed for environmental conditions. The facility failed to ensure Resident #1 bed was made with linen, leaving the bed bare and resident lying directly on the mattress. The failure placed residents, who had their mattresses placed directly on the floor , at risk for unsanitary living conditions.