Avir at La Grange

Inspectors wroteBased on observation, interview, and record review, the facility failed to make sure that drugs are stored in locked compartments and only authorized persons have access for 1 of 3 medication carts (Medication Cart #1) reviewed for drug storage and labeling. The facility failed to ensure Medication Cart #1 was locked, medications secured, and not accessible to other staff, residents, or visitors. This failure could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 13 of 64 days (first quarter of 2026) reviewed in that: The facility failed to ensure they had a RN on duty daily for 13 days of the 64 days in the first quarter from 01/2026 through 03/2026. This deficient practice placed residents at risk of missing nursing assessments, resident supervision, and skilled nursing treatment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide a private space for residents' monthly council meetings and the confidential resident group meeting during the survey for five of five residents reviewed for resident council. The facility failed to provide the Resident Council with a private meeting area to conduct their meetings. This failure could place residents 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 ensure residents received care consistent with professional standards of practice, to ensure necessary treatment and services to promote healing for two of three residents reviewed for pressure ulcers. (Resident #8 and Resident #27) A) The facility failed to ensure the ADON followed standard precautions during wound care for Resident #8's unstageable deep tissue injury (DTI) right heel pressure ulcer (is a full-thickness injury whose depth cannot be determined because the wound bed is obscured by necrotic tissue, slough, or eschar) on 03/04/2026 when she failed to clean the unstageable pressure ulcer in a manner that did not contaminate the wound. She further failed to apply the dressing to the wound as to not cause unnecessary pressure, or trap air and moisture which could hinder the healing process. [...]

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 two of five residents (Resident #8 and Resident #27) reviewed for infection control practices. A) The facility failed to ensure the ADON followed standard precautions during wound care for Resident #8's unstageable right heel pressure ulcer on 03/04/2026 when she failed to perform hand hygiene during wound care, set up a clean wound dressing field without cross contamination, use enhanced barrier precautions on a chronic wound per facility policy, or use a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program for 1 of 1 facility for 42 residents reviewed for pests. The facility failed to ensure the facility was free of pests in the dining room. This failure could place residents at risk of increased exposure to pests and vector-borne diseases and infections. Observation on 03/03/2026, at 9:21 AM this Surveyor observed 2 large size dead cockroaches in a silver pan behind the ice machine in the dining area. Observation on 03/04/2026, at 11:52 AM this Surveyor observed 2 large size dead cockroaches in a silver pan behind the ice machine in the dining area. During confidential interviews between 03/3/2026 and 03/05/2026, residents complained about roaches they observed throughout the facility (no specific dates/times provided). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure storage of medications used in the facility in accordance with currently accepted professional principles and included the appropriate expiration dates to preserve their integrity for medications stored, and to store medications properly to prevent deterioration for one of three medicaiton carts reviewed. The facility failed to ensure expired medications were removed from the 200 hall medication cart. These failures could place residents at risk of not receiving the intended therapeutic effect of the medications or contaminated medication. Findings Included: Observation on 03/04/2026 at 11:34 AM revealed the facility Unit 2 Medication cart with a bottle of Benadryl expired on 01/2026, a bottle of Meclizine expired on 01/2026, and a bottle of normal saline eye drops expired 05/2025. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide bedrooms that measured at least 80 square feet per resident in multiple resident bedrooms for 12 of 30 resident rooms (Rooms 202, 204, 207,401,403,407,501,503,504,507,509, and 510) reviewed for environment. The facility failed to ensure resident bedrooms rooms, 202, 204, 207,401,403,407,501,503,504,507,509, and 510 measured at least 80 square feet per resident. This failure could place residents at risk by limiting the amount of resident care equipment and personal belongings that could be accommodated in the resident's room. This may restrict the resident's' ability to move about the room freely and could negatively affect the residents' quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to consult with the resident's physician when there was a need for an in and out catheter and a foley catheter for 1 (Resident #1) of three residents reviewed for physician notification. 'The facility failed to notify Resident #1's provider of the need for in and out catheter and for a foley catheter on 12/21/2025. This failure could result in decreased continuity of care, and a delay in needed treatment and services.

Inspectors wroteBased on interview and record review the facility failed to ensure, a resident based on comprehensive assessment of a resident, that the resident received treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan, and the residents' choices for one of four residents (Resident #1) reviewed for quality of care. The facility failed to ensure Resident #1 had orders for in and out catheter and a foley catheter when resident began retaining urine on 12/21/2025. This deficient practice could place residents at risk of not receiving adequate care, harm, or injuries.

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 under proper temperature controls, and permitted only authorized personnel to have access to the keys for 1 of 2 medication carts ( Medication Cart #1) reviewed for medication storage. The facility failed to ensure Medication Cart #1 was locked and medications were secure and not accessible to other staff, residents or visitors. This failure could place residents at risk of having unauthorized access to prescriptions, biologicals, and over-the-counter medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety in 1 of 1 kitchen and 1 of 1 emergency food storage room reviewed for kitchen and food sanitation. 1. The facility failed to dispose of a bag labeled lunch meat with a manufacture expiration date of 11/23/24. 2. The facility failed to safely store all food items to prevent contamination or spoilage; a bag of pancakes and a bag of waffles were each in a torn bag exposed in the freezer on 12/10/2024. 3. The facility failed to ensure dietary staff followed handwashing procedures on 12/10/2024. 4. The facility failed to ensure 8 gallons of expired water (expired 04/04/24) in emergency storage were cycled out and removed and 3 additional separate damaged gallons of water removed. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents who are trauma survivors received culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences to eliminate or mitigate triggers that may cause re-traumatization for 1 (Resident #34) of 1 resident reviewed for trauma informed care. The facility failed to ensure that Resident #34 diagnosis of Post-Traumatic Stress Disorder (PTSD) potential triggers were identified, and care planned. The facility failed to ensure that Resident #34 received psychiatric services based on his current diagnosis to evaluate and plan for his care needs. This failure could place residents at increased risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to personal privacy and confidentiality of his or her personal and medical records for 1 of 2 residents (Resident #37) reviewed for personal privacy and confidentiality of records. The facility failed to protect the personal healthcare information of Resident #37 which was visible on a computer screen in the hallway while LVN A went into his room to preform wound care on 12/11/2024. This failure could place residents at risk for loss of privacy and dignity.

Inspectors wroteBased on interview and record review, the facility failed to refer all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 of 2 residents (Resident #9) assessments reviewed for PASARR evaluations. The facility failed to refer Resident #9 to the appropriate, State-designated authority when she was diagnosed 09/27/23 with psychotic disorder with delusions due to known physiological condition and psychotic disorder with hallucinations due to know physiological condition. This failure could place residents at risk for not receiving necessary PASARR mental health services, causing a decline in mental health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications and biologicals were stored in locked compartments for 1 of 1 treatment carts reviewed for medication storage. The facility failed to ensure the treatment / nurse cart was locked while unattended by LVN A on 12/11/2024. This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles.

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 and follow accepted national standards for one of one resident reviewed for pressure ulcers wound care. (Resident #37). The facility failed to ensure the LVN A followed standard precautions during wound care on 12/11/2024 for Resident #37's stage II right buttock pressure ulcer when she failed to set up a clean field for treatment supplies, used a cleaning technique on the pressure ulcer that did not cross contaminate the pressure ulcer or prevent the pressure ulcer once cleaned from becoming re-contaminated. These failures could place residents at risk for developing wound infections.

Inspectors wroteBased on interview and record review the facility failed to ensure that 49 of 49 resident rooms met the required square footage in that: All forty-nine resident rooms were less than the required space of eighty square feet in multiple resident rooms or 100 square feet for single resident rooms. This included rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 201, 202, 203, 204, 205, 206, 207, 208, 209, 301, 302, 303, 304, 305, 306, 401, 402, 403, 404, 405, 406, 407, 501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 601, 602, 603, 604, 605, 606, 607, 608. This failure could restrict the amount of resident care equipment and residents' personal effects that could be accommodated in these resident rooms, limit the ability of the residents to move about the room, and decrease residents' quality of life.

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 3 (Resident #19, Resident #32, and Resident #36) of 8 residents reviewed for accommodation of needs. The facility failed to ensure Resident #19, Resident #32, and Resident #36 had call lights within their reach. These failures placed residents at risk of not having their needs met.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain comfortable sound levels for 7 (Resident #1 and six anonymous residents) of 8 residents reviewed for homelike environment. The facility failed to ensure Resident #22 did not upset other residents in the dining room with his yelling and behaviors during meals. This failure place residents at risk of not having comfortable sound levels.

Inspectors wroteBased on interview and record review the facility failed to ensure that 49 of 49 resident rooms met the required square footage in that: All 49 resident rooms were less than the required space of 80 square feet in multiple resident rooms or 100 square feet for single resident rooms. This included rooms 101, 102, 103, 104, 105, 106, 107, 108, 109, 201, 202, 203, 204, 205, 206, 207, 208, 209, 301, 302, 303, 304, 305, 306, 401, 402, 403, 404, 405, 406, 407, 501, 502, 503, 504, 505, 506, 507, 508, 509, 510, 601, 602, 603, 604, 605, 606, 607, 608. This failure could restrict the amount of resident care equipment and residents' personal effects that could be accommodated in these resident rooms, limit the ability of the residents to move about the room, and decrease residents' quality of life.