Avir at Knox City

Inspectors wroteBased on observation and interview, the facility failed to respect the resident's right to personal privacy in 1 of 3 common hallways reviewed for privacy in that: A list of residents that received incontinence care services was posted on the wall in a hallway at a nurse charting station which was visible to potential passersby. This failure could place residents at risk of having medical information personal, or care instructions exposed to others and misuse of personal information. During an observation on 12/16/25 at 4:05 PM revealed a list of 14 residents names that received incontinence care services was posted on the wall in a hallway on the secured unit at the nurse charting station which was located across from the doorway of a dining room. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident had a right to a safe, clean, comfortable, and homelike environment in the facility and failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior in 1 of 2 common dining rooms and 10 of 33 resident rooms (24, 25, 26, 28, 30, 31, 32, 33, 34, and 35) reviewed for environment. The facility failed to ensure residents that used common areas and rooms were clean, safe, and did not need repair. These failures could place residents at risk of living in an unsafe, unclean, uncomfortable, and unhomelike environment which could cause a decline in resident psychosocial well-being.

Inspectors wroteBased on observation and interview, the facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns for 4 of 4 confidential residents. The facility failed to ensure 4 of 4 confidential residents were provided, per the facility policy through postings in prominent locations: the grievance procedure, access to grievance forms, information regarding who the facility grievance officer was with their contact information, and accommodations to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biologicals were stored properly for 1 of 2 medication carts (Medication Cart A) reviewed for medication storage. LVN B left Medication Cart A unlocked and unattended in the hallway by the nurse's station. The facility failed to ensure Medication Cart A's medications were stored separately by route. These failures could place residents at risk for drug diversion and an increased risk for medication errors.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure that the menu met the nutritional needs of residents and was followed for the lunch meal on 12/16/25 reviewed for nutritional adequacy. The facility failed to: 1) Ensure lunch item served on 12/16/2025 reflected what was on the DM's menu. 2) Ensure residents on special diet (pureed bread) receive pureed bread for the 12/16/2025 lunch meal. These failures could affect all residents who ate food from the kitchen by placing them at risk of not receiving adequate nutritive food value needed to promote/maintain health.

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 the facility's only kitchen reviewed for food safety. 1) The facility failed to ensure food items in the freezers (4), were labeled and stored in accordance with the professional standards for food service. 2) The facility failed to protect foods from potential contamination. These failures could place residents at risk for food-borne illness and cross contamination.

Inspectors wroteBased on observation and interview, the facility failed to respect the resident's right to personal privacy in 10 of 33 resident rooms (24, 25, 26, 28, 30, 31, 32, 33, 34, and 35) reviewed for privacy in that: 1. Resident rooms [ROOM NUMBERS], beds B, didn't have privacy curtains that were designed or equipped to allow for full visual privacy. 2. Resident rooms 24, 25, 26, 28, 30, 31, 32, 33, 34, and 35 had slats missing from the window vertical blinds, which allowed potential passersby to see inside the rooms. These failures could also cause residents to feel uncomfortable, disrespected, and possible exposure to anyone passing by.

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 2 of 3 residents (Resident #5 and Resident #6) reviewed for infection control.-CNA A did not perform hand hygiene after touching a trash can, before touching wipes, and did not perform hand hygiene between all glove changes when providing incontinence care to Resident #6.-LVN A did not perform hand hygiene between all glove changes when providing wound care to Resident #5. These failures could place residents at risk for cross contamination and infection.

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 the facility's only kitchen. The facility did not maintain an effective pest control program to ensure the facility was free of flies in the kitchen. These findings could place residents at risk for an unsanitary environment and a decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week in the facility for 34 (4/1, 4/3, 4/6, 4/7, 4/8, 4/10, 4/11, 4/12, 4/13, 4/14, 4/20, 4/21, 4/27, 4/28, 5/7, 5/10, 5/11, 5/12, 5/24, 5/25, 5/28, 5/29, 5/30, 5/31, 6/1, 6/2, 6/7, 6/8, 6/14, 6/15, 6/21, 6/22, 6/25, and 6/29/2024) of 91 days reviewed for RN coverage. The facility failed to maintain RN coverage of eight hours a day for 34 days. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper 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 3 of 14 residents (Resident #11, #30 and #34) and 1 of 4 staff (LVN A) reviewed for infection control. LVN A failed to properly clean a multi-use medical device between each resident during medication administration for Resident #11, #30 and #34. These failures could place residents at risk for spread of infection and cross contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for 1 (Resident #28) of 5 residents reviewed for respiratory care. The facility failed to ensure that Resident #28's oxygen tubing was replaced every seven (7) days, according to physician's orders. This failure could place residents at risk for respiratory compromise and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain clinical records in accordance with accepted professional standards and practices that were complete and accurately documented for 1 (Resident #28) of 13 residents reviewed for clinical records. The facility failed to accurately document an oxygen tubing change for resident #28. This failure could place residents at risk of inaccurate and incomplete care.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public, on facility grounds in 1 of 2 smoking areas (North patio smoking area). The facility failed to ensure the grounds in the smoking area was free from trash. This failure could attract unwanted pests and cause the facility to have an unsightly appearance.

Inspectors wroteBased on observation, interview, and record review; the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles when applicable for 2 of 7 residents (Resident #1 and #2) reviewed for pharmacy services. The facility failed to prevent the misappropriation of Resident #1's Depakote (Divalproex for mood/behavior), when LVN A took a blister pack of Depakote from Resident #2 and placed Resident #1's pharmacy label on top of Resident #2's pharmacy label. This failure could place residents at an increased risk for not receiving their prescribed medication as ordered. This failure could result in residents not receiving an accurate dose of medication as well as not being maintained at their best therapeutic level.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 1 of 8 residents (Resident #2) reviewed for accidents. The facility failed to use an appropriate transfer for Resident #2 which resulted in a fall for Resident #2 and caused Resident #2's surgical wound from a below the right knee amputation to bleed. This failure could place residents at risk for harm and further injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure a resident had the right to be free from abuse, neglect, misappropriation of property, and exploitation for 1 of 8 residents (Resident #1) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Synthroid/Levothyroxine (thyroid medication), when LVN B took the medication out LVN C's medication cart for her own personal use between 4/21/2024 through 4/28/2024 and/or 5/2/2024. This incident was witnessed by LVN C. This failure could place residents at an increased risk for not receiving their prescribed medication as ordered.

Inspectors wroteBased on interview and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 2 medication carts (medication cart on front hall). The facility failed to ensure that medication 1 of 2 medication carts were secured when unattended on or about 4/21/2024 through 4/28/2024 and/or 5/2/2024. This failure could place residents at risk of having access to unauthorized medications and/or lead to possible harm, drug overdose, or drug diversions.

Inspectors wroteBased on interview and record review the facility failed to ensure in accordance with accepted professional standards and practices, medical records maintained on each resident were accurately documented for 1 of 8 residents (Resident #1) reviewed for accuracy of records. LVN B failed to document a fall with injury in the medical record progress note for Resident #2. This failure could place residents at risk for not receiving needed care or treatment after an incident occurred.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 9 of 30 days (08/13/23, 08/19/23, 08/20/23, 08/26/23, 08/27/23, 09/02/23, 09/03/23, 09/09/23, and 09/10/23) reviewed for RN coverage. The facility failed to ensure they had RN coverage 8 hours a day, 7 days a week for the following days: 08/13/23, 08/19/23, 08/20/23, 08/26/23, 08/27/23, 09/02/23, 09/03/23, 09/09/23, and 09/10/23 This failure could place residents at risk for inconsistency in care and services.

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 1 of 1 kitchen reviewed for dietary services, in that: 1) The facility failed to ensure to date and label all food. 2) Dietary staff failed to store foods in a manner to prevent contamination. 3) Dietary staff failed to clean two vents observed in the kitchen area and the inside dry storage area. 4) Dietary Staff stored dented cans with the remaining cans used for resident consumption (. 5) Dietary Staff used 1 of 2 dented cans for resident consumption on 09/13/23. 6) Dietary Staff failed to properly thaw chicken 7) Dietary staff failed to cover food that was not actively being served. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bladder or had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 3 Residents (Resident #28 and #40) reviewed for incontinent care. 1. CNA A failed to proper clean penis and buttocks while providing incontinent care to Resident #28. 2. TNA B used multiple swipes with the same wipe across resident #40 abdomen and buttocks while providing incontinent care to Resident #40. These failures had the potential to affect residents by placing them at an increased risk of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menu was followed, for 2 out of 2 residents that received pureed food (Residents #26 & 33), in that: 1. The facility failed to ensure Resident # 26 received pureed bread on 09/13/23 and on 09/14/23. 2. The facility failed to ensure Resident # 33 received pureed bread on 09/13/23 and on 09/14/23 These failures could place residents at risk for unwanted weight loss, hunger, unwanted weight gain, and metabolic imbalances.

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 2 of 2 puréed meals (9/13/23 - Lunch and 09/14- Lunch) observe for 2 of 2 residents with orders for puréed diet (Residents #26 and 33); in that: The facility failed to provide food that was in a form to meet resident needs Residents #26 and #33 with the orders for puréed diets. This failure could place residence at risk of decreased food intake and choking.