Avir at Jeffrey Place

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure food safety by not labeling & dating food correctly, wearing hair restraints, and sanitizing equipment during food service. These failures could place residents at risk for foodborne illnesses.

Inspectors wroteBased on 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, to meet the need of each resident. The facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation at each shift change on one of two medication carts reviewed for shift change reconciliation documentation This failure could place residents at risk of drug diversions and could result in diminished health and well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents were free of any significant medication errors for 2 of six residents (Resident #4 and Resident #46) reviewed for medication errors. The facility failed to administer scheduled time-sensitive medication to Resident #4 on 04/09/26. The facility failed to administer scheduled medications to Resident #46 on 04/07/2026. This deficient practice could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements, worsening or exacerbation of chronic medical conditions, and hospitalization.

Inspectors wroteBased on 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) for 4 (Resident #1, #2, #3, and #4) of 15 residents reviewed for accurate medical records. The facility failed to ensure the accuracy of Resident # 1, #2, #3 and # 4's, pain PRN narcotic drug record versus residents' eMARs for June and July 2025. The documentation between the two records did not match. This deficient practice could result in errors in care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident received adequate supervision and assistive devices to prevent accidents for 1 of 3 residents (Resident #2). On 5/30/2025 at approx. 12:00 p.m., CNA D had been providing incontinent care to Resident #2. While care was being provided, the resident rolled off the bed onto the floor, hitting his face on the nightstand. Resident #2 sustained swelling and redness to the right side of his face, redness to his right knee, and required admission to the hospital on 5/30/25, for further treatment. A review of the care plan dated 5/20/20 reflected that Resident #2 required one-person assistance for bed mobility and transfers. And two-person assistance for ADL care. The noncompliance was identified as PNC. [...]

Inspectors wroteBased on the interviews and record review the facility failed ensure residents were free of any significant medication errors for 1(resident # 1) of 6 reviewed for significant medication errors. The facility failed to ensure Resident #1 received his prescribed medications. According to residents' #1 MAR the missed medications are: Insulin glargine prescribed for diabetes, Lactulose prescribed for weakness, Allopurinol prescribed for hypertension, Clotrimazole prescribed for a disorder of the skin, Docusate sodium prescribed for obesity, fish oil prescribed for hyperlipidemia, Gabapentin prescribed for type 2 diabetes mellitus with foot ulcer, Rosuvastatin prescribed for hyperlipidemia, Tamsulosin prescribed for diabetes mellitus, and Valsartan prescribed for hypertension according to the physicians' orders on June 5, 2025 and June 6, 2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, and serve food under sanitary conditions in 1 of 1 kitchen when they failed to: A. Ensure staff did not use bare or gloved hands when serving food. B. Ensure stored food was properly labeled, dated and stored. These failures placed all residents who ate food served by the kitchen at risk of cross contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a safe, clean, comfortable, and homelike environment was provided for 1 of 16 resident (Resident # 19) and 1 of 1 facility observed for environment 1. Hall 2 and Hall 4 had residue on the floor causing it to feel sticky while walking. 2. Hall 2 had a roach walking across the floor. 3. Resident #19's room was not homelike with her personal items stacked up against the wall, gnats flying around resident's face. 4. Gnats flying around in the conference room. 5. Phone outlet in the unlocked conference room was hanging out of the wall and wires attached. These failures could affect residents by placing them in an uncomfortable and unsanitary environment.

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 5 (LVN F, CNA I, CNA J, CNA K, and LVN G) of 5 staff reviewed for resident care -LVN F came out of resident room fully donned in PPE. -LVN F did not clean glucometer before or after checking glucose level for Resident #61. -CNA I did not perform hand hygiene or glove change during incontinent care of Resident #31. -CNA J wore gloves from the hallway into Resident #31's room to assist with incontinent care. -CNA J did not perform HH or glove change during incontinent care of Resident #31. -CNA K did not retract foreskin for cleaning procedure indicated in catheter care for Resident #265. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident had a right to reside and receive services in the facility with reasonable accommodation of the residents needs and preferences for 1 of 16 residents (Resident #14) reviewed for accommodation of needs. Resident #14's call light was not within her reach. The call light was located at the bottom of the bed out of reach of the resident. This failure could place residents at risk of not having their needs met and a decline in their quality of care and life.

Inspectors wroteBased on record review and interview, the facility failed to ensure the right to receive written notice of a room change before the change was made for 1 of 16 residents (Resident #19) reviewed for right to receive written notification in that: The facility did not provide evidence that Resident #19 was given a written notice of a room change before the resident was moved. This failure could place all residents at risk for being displaced without notice and/or reason and decrease quality of life being in a new environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive care plan for each resident, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment for 1 of 16 (Resident #43) reviewed for care plans. This facility failed to implement the comprehensive care plan for Resident #43, resulting in ineffective communication. This failure could place residents at risk of not receiving the care needed to live at their highest practicable level of health and mental well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable for 1 (Resident #43) of 16 residents reviewed for activities of daily living. The facility failed to work with Resident #43 on using his communication device to communicate effectively. This failure could place residents with communication deficits in danger of being unable to communicate and thereby experiencing a decrease in quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice for 1 of 24 residents (Resident #25) reviewed for physician orders for treatments. In six observations over three days, the facility failed to follow physician orders and apply Resident #25's hearing aid as ordered for Resident # 25. The failure could affect residents currently residing in the facility resulting in not receiving needed care to maintain optimum health and placing them at risk for injury and/or deterioration in their condition.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure respiratory care, including tracheostomy care and tracheal suctioning was provided consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #24) of 16 residents reviewed for respiratory care. The facility failed to ensure Resident #24's oxygen was set to the 4 lpm indicated in her physician's order. This failure could place residents who receive oxygen at an increased risk for hypercapnia (too much carbon dioxide in the blood), pulmonary oxygen toxicity (damage to the lung lining tissues and air sacs), hypoxemia (low levels of oxygen in the blood, decreasing the oxygen supply to vital organs), and shortness of breath. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review, it was determined the facility failed to ensure drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles and include the appropriate accessory and cautionary instructions, and the expiration date when applicable on 2 of 3 medication carts (Hall 200 and Hall 300) reviewed for medication storage. -Medication cart for 200 Hall had 9 medication cups with multiple medications in them for unidentified residents in top drawer of medication cart. -Medication cart for 300 Hall had Lantus Solo-star for Resident #33 with no open date. -Medication cart for 300 Hall had Insulin Aspart for Resident #61 with no open date. -Medication Triamcinolone acetonide cream was on Resident #27's bed. [...]

Inspectors wroteBased on record review and interviews, the facility failed to provide and document sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility for one (1) of one resident reviewed for transfer and discharge rights. (Resident #2) The facility failed to plan for a safe discharge for Resident #2. This failure could place residents at risk for not receiving care and services to meet their needs upon discharge.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for five of six residents (Residents #1, Resident #2, Resident #3, Resident #4, and Resident #5) reviewed for quality of life/ADL care. The facility failed to ensure nailcare was completed for Resident #1, Resident #2, Resident #3, and Resident #4's and to ensure Resident #5 received a timely response for incontinent care. This failure could place residents at risk for poor hygiene, infections, dignity issues, embarrassment, humiliation, and decreased quality of life.

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were in locked compartments and inaccessible to unauthorized staff, visitors, and residents for 2 of 4 medication carts (Med Cart #1 and Med Cart #2) reviewed for medication storage in that: The facility failed to prevent: Medication Cart #1 being unattended and unlocked in the doorway to dining room on 7/17/2024. Medication Cart #2 being unattended and unlocked across from the nurses' station on 7/17/2024. This failure could allow residents unsupervised access to prescription and over-the-counter medications. Findings Include: Observation on 07/17/2024 at 9:10 am revealed, Med Cart #1 sitting near the entrance to the dining room. Med Cart #1 was unsupervised and unlocked. [...]

Inspectors wroteBased on interview and record review, the facility failed to notify the resident representative regarding a change in the resident's condition, for one (Resident #2) of six residents reviewed for changes in condition. , in that: The facility failed to inform Resident #2's Representative (RP) when Resident #2 was found in Resident #1's room on 5/25/2024 while Resident #1 was masturbating behind his curtain . This failure could place residents at risk of not having their Responsible Party notified of changes resulting in a delay in decision making for medical interventions.

Inspectors wroteBased on interviews and record reviews the facility failed to implement a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and psychosocial needs for one resident (Resident #1) of six (6) residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was updated and revised to reflect inappropriate sexual behaviors towards staff. This failure placed residents at risk of not having their individualized needs met in a timely manner and communicated to providers and could result in a decline in physical and psychosocial well-being.

Inspectors wroteBased on Interviews and record reviews, the facility failed to ensure residents were free from verbal abuse for one of 6 residents reviewed for abuse. The facility failed to prevent verbal abuse for Resident # 1 as self-reported by CNA A when she responded in the smoking area to Resident # 1 one yelling at her and calling her a Bitch, by repeating the statement to the resident. The noncompliance was identified as Pass noncompliance that began on 4/21/2024 and ended on 4/22/2024. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for psychosocial harm and further abuse.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure in accordance with state and federal laws, all drugs and biologicals were stored in locked compartments, for 1 of 4 medication carts review for medication storage that Medication cart # 1 was left unattended and unlocked in the hallway not facing the wall. This failure could allow resident, unsupervised access to prescription and over-the-counter medication, and can result in the resident can receive medication that had not maintained the effectiveness due to lack of temperature management or proper labeling. Finding Include: Observation on 5/7/2024 at 3:06pm revealed a medication cart in front of a resident's room, unlocked with the top drawer slightly opened and no staff member in site. Upon inspection the medication cart had medical supplies, prescription and over-the counter medications. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for Resident #1 of 7 residents reviewed for accidents and supervision. The facility failed to ensure Resident # 1 was free from accidents. Resident # 1 eloped from facility on 3/16/2024. Resident # 1 was located two blocks from that facility at a local convenient store that was on busy high traffic road. Resident #1 was found walking in the opposite direction of the facility, disoriented, and confused when facility RN A located her. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 4/5/202 at 11:30am. The IJ Immediate Jeopardy template was provided to the ADM on 4/5/2024 at 11:30am. [...]

Inspectors wroteBased on interview and record review, the facility failed to protect 2 resident (Resident # 3 and Resident #4) of 7 residents reviewed for abuse. Resident # 3 reported that LVN E called her stupid and incompetent. Resident #3 stated this made her upset. Resident # 4 reported that LVN E touched her inappropriate by rubbing her shoulder and thigh. Resident # 4 stated this made her feel uncomfortable. This failure caused these residents to be abused, this failure also places other residents at risk of being abused.

Inspectors wroteBased on interview, and record review the facility failed to permit a resident to return to the facility after being hospitalized or placed on therapeutic leave for 1 (Resident # 2) of 7, residents reviewed for bed hold. Resident # 2 was not permitted to return to the facility after being discharged from the hospital. The facility refused to allow Resident #2 to return to the facility after he was cleared for psychiatric services needed and assessed from a recent fall. Resident # 2 was clear to discharge back to the facility on 3/31/2024. This failure could place the resident at risk of not getting the care and services required.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a private space for residents' monthly council meetings for 7 of 7 confidential residents reviewed for Resident Council. The facility did not provide a private space for resident council meeting. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a safe, functional, sanitary, and comfortable environment for 1 (room [ROOM NUMBER]) of 12 resident rooms, 1 (400 hall shower room) of 6 shower rooms, and 1 (400 Hall) of 4 halls reviewed for environment. The facility failed to ensure the ceiling in room [ROOM NUMBER] was free from a hole in the tile, a drooping tile with water stains and dust surrounding the air vent, and a hole in the wall beneath his window. The facility failed to ensure the walls, floor, and bathroom fixtures were clean and in good repair in the 400 Hall shower room. The facility failed to ensure the ceiling remained free from water leaking onto the hallway floors. These failures could place residents at risk of a diminished quality of life due to an unsafe and unmaintained environment.

Inspectors wroteBased on interview and record review the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that include measurable objectives and time frames to meet residents' mental and psychosocial needs for 6 Residents ( #10, #40, #6, #31,#25 and #51) out of 6 reviewed for care plan. The Minimum Data Set Coordinator did not update Resident #10, Resident#40, Resident#31, Resident#5 and Resident #51 care plan to reflect the personal refrigerator in the resident's room. This failure could place the 6 residents at risk for unmet care needs.

Inspectors wroteBased on interview and record review, the facility failed to conduct a performance review of nurse aides at least once every 12 months and provide regular in-service education based on the outcome of these reviews for 3 of 3 CNAs (CNA D, CNA E, and CNA F) CNAs who worked at the facility more than a year. The facility failed to conduct performance reviews at least every 12 months for CNA D, CNA E, and CNA F. This deficient practice could result in residents not receiving the necessary care and services due to nurse aides not receiving training based on their identified needs.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to follow their policy regarding storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling and consumption of the food and beverages for 6 Residents ( #10, #40, #6, #31,#25 and #51) out of 6 reviewed for personal food storage. The facility staff did not label and date Resident #10, Resident #40,Resident #6, Resident#31, Resident #25 and Resident#51 food and beverages. The facility staff did not clean out resident #10, Resident#40, Resident #6, Resident#31, Resident #5 and Resident#51 personal refrigerators on a schedule or as needed. The Minimum Data Set Coordinator did not update Resident #10, Resident#40, Resident#31, Resident#5 and Resident #51 care plan to reflect the personal refrigerator in the resident's room. [...]

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 3 of 6 residents (Residents #32, #38, and #50) reviewed for infection control. MA C failed to sanitize a re-useable blood pressure cuff between blood pressure checks on Residents #32, #38, and #50. This failure could place residents at risk of contracting or spreading an infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided with such care, consistent with professional standards of practice for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for respiratory care, in that: The facility failed to change oxygen tubing weekly as ordered and ensure the oxygen tubing was bagged while not in use for Resident #1, Resident #2, and Resident #3. These deficient practice could place residents that receive oxygen therapy at risk for inadequate care and respiratory infection. Findings Included: Review of Resident #1's undated face sheet reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including chronic obstructive pulmonary disease (a type of progressive lung disease), wheezing, and generalized muscle weakness. [...]