Avir at Heritage

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were treated with respect and dignity and to provide care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 1 of 1 dining area reviewed for dining and 1 of 6 residents (Resident #34) reviewed for resident rights. The facility failed to ensure all residents at one table, to include Resident #65, were served their meals before moving on to the next table for 06/16/2026 lunch. The facility failed to ensure CNA N knocked on 4 residents' rooms, to include Resident #34, before entering. These failures could result in the loss of dignity of residents and decreased quality of life. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assure the accurate acquiring, receiving, dispending, and administering of all drugs and biologicals, to meet the needs of each resident for 3 of 8 residents (Resident #9, # 117 and #22) reviewed for pharmacy services. 1. The facility failed to ensure Resident #22's propylene-glycol (MiraLAX) was administered as ordered by a physician. 2. The facility failed to ensure Resident #9's glucosamine-chondroitin was administered as ordered by a physician. 3. The facility failed to ensure Resident #117 had blood pressure parameters set up as a prompt to complete before administering Midodrine and Amiodarone. These failures could place residents at risk of missed medication dosages and could lead to ineffective symptom management or treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure there were no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for one of one kitchen. The facility failed to ensure that there was no more than 14 hours between dinner and breakfast the following day or offer a snack when mealtimes span was greater than 14 hours. This failure could affect all residents who received meals served from the facility's only kitchen by placing residents at risk for unplanned weight loss, and side effects from medication given without food, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food for 1 of 1 kitchen in accordance with professional standards for food service safety. 1. The facility failed to correctly label salsa with its proper use-by date in the reach-in refrigerator located in the food preparation area. 2. The facility failed to label ranch dressing with a use-by date in the reach-in refrigerator located in the food preparation area. 3. The facility failed to throw out cucumbers, that were exposed to air, from the walk-in refrigerator because they became soft and not servable to residents. 4. The facility failed to have a place to document the temperature for alternate foods for 06/18/2026 lunch. These failures could place residents at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, 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 diseases and infections for 2 of 8 residents (Residents #9 and #76) reviewed for infection control.1. The facility failed to ensure MA E utilized contact isolation precautions when administering medications to Resident #9. 2. The facility failed to ensure CNA L and CNA M utilized EBP when providing peri-care to Resident #76. These deficient practices could affect all residents who receive care, placing them at risk of infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for 1 of 6 residents (Resident #74) reviewed for resident rights. The facility failed to obtain signed consent for psychotropic (a medication that affects brain function and used to treat psychiatric conditions) antidepressant medication, Sertraline for Resident #74. [...]

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 2 of 8 (Resident #59 and Resident #114) residents who were observed for call light placement. The facility failed to ensure the call light was within reach for Resident #59 and Resident #114. This failure could place residents at risk of not being able to call for help as needed.

Inspectors wroteBased on interview and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 6 residents (Residents #9 and #29) reviewed for assessments. 1. The facility failed to accurately reflect weight loss of 5% or more in the last month on Resident #9's quarterly MDS assessment, dated 06/02/2026. 2. The facility failed to accurately reflect weight loss of 5% or more in the last month on Resident #29's quarterly MDS assessment, dated 05/26/2026. These failures 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 baseline care plan for each resident that included the instructions needed to provide effective and person-centered care of the resident that met professional standards of quality care within 48 hours of a resident's admission, including initial goals based on admission orders, physician orders, dietary orders, and social services for 1 of 6 residents (Resident #129) reviewed for baseline care plans. The facility failed to ensure a pain baseline care plan was completed within 48 hours from admission for Resident #129. The failure could place newly admitted residents at risk for not receiving care and services as needed.

Inspectors wroteBased on observation, 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 included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 2 of 8 residents (Resident #1, and #9) reviewed for care plans.1. The facility failed to ensure Resident #9's comprehensive care plan included information for a UTI caused by MRSA and the need for contact isolation precautions. 2. The facility failed to ensure Resident #1's comprehensive care plan included information for multiple wounds and wound care. These failures could place residents at risk for not having their needs and preferences met.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who need respiratory care were provided such care, consistent with professional standards of practice for 1 of 2 residents (Resident #105) reviewed for respiratory care. The facility failed to ensure Resident #105's oxygen concentrator was set to 3 liters per minutes as ordered by physician. This failure could place residents at risk of illness, respiratory complications and accidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals were secured properly within 1 of 4 medication carts (nurse cart on 100 hall) observed for medication storage. One small yellow capsule, one small round while pill and one small round red pill were observed in the bottom drawer of the nurse cart on the 100 hall. This failure could place residents at risk of missing or misuse of drugs by unauthorized personnel.

Inspectors wroteBased on interview and record review the facility failed to develop policies and procedures to ensure the resident's medical record included documentation that indicated, at minimum that the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization and influenza immunizations and that the resident either received the pneumococcal immunization and influenza immunizations or did not receive the pneumococcal immunization and influenza immunization due to medical contraindication or refusal for 2 of 5 residents (Residents #1 and #12) reviewed for immunizations. 1. The facility failed to ensure Resident #12 had record of receiving education or being offered the pneumococcal vaccine and influenza (flu) vaccine and education.2. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program so that facility was free of pests and rodents for 1 of 6 resident's rooms (Resident #117). The facility did not maintain an effective pest control program to ensure the facility was free of multiple black flying things in Resident #117's room. This failure places residents at risk of frustration, anxiety, and could result in the residents not having a safe, sanitary environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices, complete, accurately documented, readily accessible, and systemically organized medical records for 2 of 5 residents (Residents #1 and #2) reviewed for accurate records. 1. The facility failed to document wound care treatments for Resident #1 for two days - 05/22/2026 and 05/23/2026. 2. The facility failed to document wound care treatments for Resident #2 for one day - 05/31/2026. These failures placed residents at risk for untreated or unmanaged wound care by inaccurate and missing records documentation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet a resident's medical needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for care planning. The facility failed to develop a care plan for Resident #2 that included the resident's NPO status. This failure could result in residents not receiving proper care.

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 diseases and infections for 1 of 3 residents (Resident #2) reviewed for infection control. The facility failed to ensure staff implemented EBP when providing care for Resident #2. This failure could lead to infection or illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public on 1 of 4 resident rooms (room [ROOM NUMBER]) reviewed for environmental concerns in that: The facility failed to repair a bathroom door, repair a broken toilet, and secure a sprinkler system access panel in resident room [ROOM NUMBER]. These failures could place residents at risk of a diminished quality of life due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on interview, and record review, the facility failed to review and revise Resident Care Plans after each assessment for 3 of 6 Residents (Resident #23, # 43, and #51) whose records were reviewed for care plan revision/timing, in that: The care plans of Residents #23, #43, and #51 were not updated to reflect thickened liquids. Thisdeficient practices could affect any resident and contribute to Residents not receiving the care and services they need.

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 reviewed, in that: 1. There were crumbs and paper food wrapping in the fryer. 2. There were sand-like particles on top of the dish washing machine. 3. Three packages of corn beef and a box of potatoes were undated in the refrigerator. 4. A box of corn dogs was unsealed and undated in the refrigerator. 5. A box of hamburger patties were unsealed in the freezer. These deficient practices could place residents who consume meals and snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on the interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program for residents with newly evident or possible severe mental disorder for 1 of 4 Residents (Resident #63) whose records were reviewed. The facility failed to refer Resident #63 for a Level I screen after being 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 PASARR.

Inspectors wroteBased on observation, interview, and record review, the facility failed to prepare puree food by methods that conserve nutritive value flavor and ensure food was prepared in a form designed to meet individual needs for 1 of 1 meal (lunch) reviewed, in that: 1. The Spinach, Macaroni and Cheese and Bread were not pureed to a pudding or mashed potato consistency as required for food served to residents who received a pureed diet. 2. The facility failed to follow the Puree Bread recipe for 4/24/2025 lunch. This deficient practice could place residents who received pureed diets at-risk for poor intake, difficulty chewing, and/or choking.

Inspectors wroteBased on observation, interviews, and record reviews, 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 1 of 5 residents (Resident #85) reviewed for infection control, in that: 1. While providing incontinent care for Resident #85, CNA A did not change her gloves or wash her hands after touching the bed remote before starting to provide care. CNA B did not change her gloves or wash her hands after touching the privacy curtain before starting to provide care. These deficient practices could place residents at-risk for infection due to improper care practices.

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 1 of 4 residents (Resident #1) reviewed for infection control. The facility failed to ensure LVN E followed infection control practices during wound care for Resident #1 on (3) occasions on 4/3/25. This deficient practice may affect residents who require wound care treatments and could place residents at risk for cross contamination and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with profession standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 4 residents (Resident #1) reviewed for pressure ulcers. 1. The facility failed to provide wound care treatments/dressing change to Resident #1' left ischium according to professional standards; in that LVN E did not clean the wound prior to applying clean dressing and did not secure the clean dressing once applied on 4/3/25. 2. The facility failed to provide wound care treatments/dressing change to Resident #1's right glute according to physician order on 4/3/25; in that LVN E applied a wet-to-dry dressing to Resident #1's glute when the order stated to apply hydrofera blue dressing. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure medical records were kept in accordance with professional standards and practices and were complete and accurately documented for 1 of 4 residents (Resident #1) reviewed for accuracy of records. The facility failed to ensure Resident #1's treatments were documented per facility policy on (2) occasions on 4/3/25. These deficient practices could place residents at risk for improper care due to inaccurate records.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a resident's responsible party was informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose alternative options is he or she preferred for 1 (Resident #3) of 6 residents reviewed for the right to be informed and make treatment decisions. The facility failed to notify Resident #3's responsible party on 09/20/2024, prior to Resident #3 being referred to a Wound Care Physician for an evaluation and received a wound debridement. This failure could affect residents and/or responsible parties by placing them at risk of not receiving treatments or being informed of treatment options.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the interdisciplinary team determined an individual may self-administer drugs in a safe practice for 1 of 6 residents (Resident #1) reviewed for administration of medications. The facility failed to ensure Resident #1 has a specific written order to self-administer her own medications on 03/18/2025 as per the facility policy for a nasal spray and eye drops. This failure could affect residents who self-administer medications by placing them at risk of not receiving their physician ordered medication treatment to meet their individual needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the accurate administration of medications for 1 (Resident #1) of 6 residents reviewed for medication administration. MA A failed to administer Resident #1's medications and failed to observe Resident #1 take her medications on 03/18/2025. This failure could affect residents who receive medications from MAA by placing them at risk for medication errors and receiving less than therapeutic benefits from medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure coordination of care with the Hospice agency, specific to each patient, for 1 Resident (R#3) of 6 residents reviewed for hospice services. Resident #3 was evaluated by a Wound Care Physician on 09/20/2024 and had a surgical wound debridement without hospice being notified of the evaluation and treatment. This failure could affect residents who received Hospice services by placing them at risk for services and treatments not being coordinated.

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 2 of 2 residents (Resident #1 and #2) reviewed for infection control: 1. The facility failed to ensure CNA A wore a gown and gloves when feeding Resident #1 who had been identified as requiring contact isolation. 2. CNA D touched new and clean brief with his old and dirty gloves after cleaning Resident #2's bowel movement when CNA D provided incontinence care to Resident #2 on 02/13/2025. These failures could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interviews and record reviews, 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 3 residents (Resident #71) reviewed for pharmaceutical services. The facility failed to follow up on a medication order resulting in the medication not being available for 10 days 02/13/2024-02/22/2024 and did not supply the medication out of the emergency kit for Resident #71. This failure could result in discomfort and pain, diminishing the resident's well-being and quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that each resident received food that was served at a safe and appetizing temperature for 6 (Resident # 4, #8, #15, #19, #44, and #80) of 21 Residents reviewed for palatable food in that: Residents #4, #8, #15, #19, #44, and #80 reported receiving cold food at mealtimes. This failure could place residents at risk of not being satisfied with their food or encouraged to increase their personal food intake with an outcome of weight loss and a diminshed quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments and permit only authorized personnel to have access to the keys for 1 of 7 (Nurse cart 100) medication carts reviewed for drug storage. The facility failed to ensure staff locked the nurse 100 hall medication cart when it was left unattended. This failure could result in harm due to unauthorized access to medications, misappropriation, and drug diversion.

Inspectors wroteBased on observations and interviews, the facility failed to post in a place readily accessible to residents, family members, and legal representatives of residents, the results of the most recent survey of the facility and failed to post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public for 1 of 1 facilities, for 2 of 4 days during survey. The facility did not have a sign posted indicating where the survey results were and did not have the survey results available and accessible to residents and visitors on 2/20/24 and 2/21/24. This failure resulted in residents, family members, and legal representatives of residents being unable to access prior survey results.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure, in accordance with accepted professional standards and practices , maintain medical records on each resident that accurately documented for 1 of 3 residents (Resident #1) reviewed for accurate medical records, in that: LVN A signed the Narcotic sheet for Resident #1 and had not initialed MAR (medication administration record), indicating inaccurate documentation. This deficient practice could result in misinformation about the professional care provided.