Avir at Itasca

Inspectors wroteBased on observation, record review, and interview the facility failed to ensure 3 of 7 residents, Resident 1, Resident #2, and Resident #3 reviewed for admission to the secured unit were free from involuntary seclusion. The facility failed to ensure Resident #1, Resident #2, and Resident #3, had no physician's order for admission to the secured unit. The failures placed all residents on the secured unit at risk of not being assessed properly, not meeting the criteria to be placed on the unit, diminished quality of life and involuntary seclusion.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for 1 of 1 facility observed. A)The facility failed to ensure the walls in the secure unit were free of gouges, scuffs, holes, peeling paint, and shredded sheetrock. The facility failed to ensure the handrails in the secure unit were free from peeling paint. The facility failed to ensure the blinds in the secure unit dining room were not broken. The facility failed to ensure the community shower room toilet was clean from feces and urine. The facility failed to ensure the floor tile was not broken and missing in the hallway in front of the kitchen entrance. [...]

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 in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure stored food in 1 of 2 reach in refrigerators were labeled and dated. The facility failed to ensure expired items were removed from dry storage and discarded. The facility failed to ensure Dietary Aide A properly sanitized a food thermometer when taking food temperatures for lunch services on 01/07/26. These failures could place residents who received prepared meals from the kitchen at risk for foodborne illness and cross-contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to be treated with respect and dignity during personal care for 1 of 6 residents (Resident #39) reviewed for respect and dignity in that:The facility failed to ensure RN A provided resident care with the door shut during an observation on 1/7/2026 at 9:13 am of wound care. The failure could place residents at risk for a lack of privacy.

Inspectors wroteBased on observation, interview, and record review, 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 #39) of 6 residents reviewed for infection control practices. The facility failed to ensure RN A used a clean technique on Resident #39's right and left foot ulcers during an observation of wound care on 1/7/2026 at 9:13 am. The failure could place residents at risk for healthcare associated cross contamination leading to worsening pressure ulcers, discomfort, pain, and potential infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control. The facility failed to keep an effective pest control program to ensure areas including residents' rooms and kitchen (dry storage) were free of flies and gnats. This failure could place residents at risk for reduced quality of life and poor sanitary environment. An observation on 01/06/26 at 10:00 AM, in the kitchen revealed a swarm of gnats surrounding a box of spoiled bananas and 50-pound bag of spoiled onions in the dry storage room. An observation on 01/06/26 at 11:41 AM, in Resident #20's room observed gnats in the room and near 3 full bedside urinals. Urine odor noted in the room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 7 of 12 residents reviewed for environment. 1. The facility failed to ensure the secure unit was a comfortable temperature on 11/26/24, and Residents #1, 2, 3, 4, 5, and 6 felt uncomfortably cold. 2. The facility failed to ensure Resident #7's room was free of holes, paint scuffs, and had a well-fitting screen for the window. These failures placed residents at risk of discomfort and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain the resident's privacy during wound treatments for 2 of 2 resident (Residents #8 and #13) reviewed for privacy. The facility failed to ensure Dr-B and the ADON protected the resident's privacy by closing the curtain and/or the resident's door when performing wound care on Resident #8 and Resident #13. This failure could place residents at risk for embarrassment, shame, and loss of dignity.

Inspectors wroteBased on interviews and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 residents (Residents #36) reviewed for resident assessments. The facility failed to ensure Resident #36's Quarterly MDS reflected that Resident #36 primary diagnosis of orthostatic hypotension. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments.

Inspectors wroteBased on 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 included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 4 residents (Residents #36) reviewed for comprehensive care plans. Resident #36's comprehensive care plan did not reflect Resident #36's primary diagnosis of orthostatic hypotension. This deficient practice 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 maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 residents' (Resident #34) refrigerators reviewed. Resident #34's personal in-room refrigerator was not monitored for safe temperatures. This deficient practice could place residents who had personal in-room refrigerators at risk of food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to notify the Resident representative when the Resident experienced a significant change in condition for 1 (Resident #1) of 7 Residents reviewed for Resident rights. The facility failed to notify Resident #1's Family Member or Hospice Agency of his x-ray results that showed he had a left hip fracture on 05/15/24 due to Resident #1 falling on 05/14/24. The facility failed to notify Resident #1's Family Member or Hospice Agency that he was transferred to the hospital on [DATE] due to the left hip fracture which was revealed from an x-ray taken on 05/15/24 due to Resident #1 falling on 05/14/24. This failure could result in the Resident representative not being aware of conditions that may require them to make medical decisions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and kitchen safety. The facility failed to label and date food products io the refrigerator and thaw foods appropriately. There failures could place residents at risk for food-born illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide at least 80 square feet per resident in multiple resident bedrooms for 8 of 82 (Rooms #'s 16, 17,18, 19, 20, 21, 22 and 23) resident rooms reviewed for square footage. Rooms 16, 17,18, 19, 20, 21, 22 and 23 which were double occupancy were not 80 square feet per resident. This practice could result in overcrowding in resident rooms.