Avir at Lancaster

Inspectors wroteBased on observations, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included describing the services to be furnished to attain or maintain measurable objectives to meet the resident's highest practicable physical, mental, and psychosocial well-being for 1 (Resident #1) of 7 residents reviewed for care plans. The facility failed to follow Resident #1's care plan to have staff near him during meals to ensure he did not take other residents' food when resident #1 choked and vomited on 05/07/26 resulting in staff performing the Heimlich. This failure could place residents at risk of not receiving individualized care and services to meet their needs.

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) to meet the needs of each resident for 1 of 3 Residents (Resident #1) reviewed for medication and pharmacy services. The facility failed to administer Resident #1's blood pressure medications in accordance with physician's orders, by not obtaining his blood pressure prior to medication administration. This failure could place residents at risk of not receiving therapeutic dosages of their medications.

Inspectors wroteBased on observation and interview the facility failed to store all drugs and biologicals in locked compartment and permit only authorized personnel to have access to the keys for 1 (medication cart #1) and 1 (crash cart #2) of 3 medication carts observed for medication and biological storage. On 06/30/26, LVN A failed to ensure medications were secured or attended to by authorized staff when LVN A did not lock medication cart #1. On 06/30/26, the facility failed to ensure crash cart #2 (a wheeled container carrying medicine and equipment for use in emergency resuscitations) was secured. These failures place residents at risk of unauthorized access to medications and biologicals. Findings Included: During an observation on 06/30/26 at 6:42 A.M., one medication cart #1 and one crash cart #2 were unlocked with drawers facing outward towards the hallway at the North nursing station. [...]

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for 1(Resident #1) of 6 residents reviewed for baseline care plan. The facility failed to include on baseline care plan that Resident #1 was placed in the secure unit. The facility failed to include on baseline care plan that Resident # 1was an elopement risk. The facility failed to include Resident #1 Behaviors on baseline care plan. These failures place residents at risk of not receiving the care needed.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the residents had a right to a safe, clean, comfortable and homelike environment. The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for four (Residents #1, # 2, #3 and anonymous) of eight residents reviewed for resident rights. The facility failed to ensure Residents #1, #2, #3's and anonymous' rooms and bathrooms were free from accumulated dirt, uneven/mix matched and missing floor tiles, rust stained bathroom fixtures and broken ceiling panel. These failures could place residents at risk of preventing residents from having a homelike experience which could cause illnesses, infections and hazards and could result in deteriorating health and decreased psycho-social well-being.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to personal privacy and confidentiality or 3 (Resident #1, #2, and #3) of 3 reviewed for personal privacy. The facility failed to ensure CNA-A did not use her personal phone to record Residents #1, #2, and #3 and posted the images to her public social media platform without permission from the residents or representatives. This failure could place residents at risk of psychological harm. Photo observed on public social media of CNA-A revealed Resident #1 smiling and looking toward the camera with the caption, Memory care everyone daddy [Resident #1's nick name] says he remembers some words. CNA-A's photo was in the middle right side of the photo with 16.5 hearts, 471 comments, 487 saves, and 3,752 shares. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide or obtain radiology and other diagnostic services to meet the needs of its residents for 1 (Resident #1) of 3 residents reviewed for radiology services. The facility failed to obtain the x-ray and results for Resident #1's leg and knee in a timely manner, resulting in a delay to diagnoses of Resident #1's right femur and right knee. The STAT x-ray should be completed as soon as possible. On 04/11/26 at 2:14 PM an Immediate Jeopardy (IJ) was identified. While the IJ was removed on 04/11/26, the facility remained out of compliance at a severity level of Immediate Jeopardy to resident health or safety and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their Plan of Removal. On 04/11/26 at 2:14 PM an Immediate Jeopardy (IJ) was identified. [...]

Inspectors wroteBased on interview, observation and record review, the facility failed to provide a safe environment and adequate supervision for 1 (Resident #1) of 5 residents reviewed for falls. The facility failed to ensure Resident #1 received adequate supervision when she had a fall that resulted in a fractur to her right thigh and right knee. This failure could place residents at risk for injuries and a decline in health.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for 1 of 3 residents (Resident #44) reviewed for contracture management. The facility failed to provide equipment/services for Resident #44's left hand contracture (a permanent tightening of the muscles). This failure could place residents at risk for a decline in range of motion, decreased mobility, worsening of contractures, and a decline in physical capabilities.

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 for kitchen sanitation. The facility failed to ensure kitchen food processor equipment was clean and free from build-up. [NAME] F placed food containers of the lunch meal in the steamtable that contained contaminated tinted water and burnt food particles floating in it on 01/14/26. 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 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, mental, and psychosocial needs that were identified in the comprehensive assessment for 1 of 15 residents (Resident #44) reviewed for care plans. The facility failed to develop a care plan with measurable objectives and timeframes to address Resident #44's left hand contracture. This failure could place residents at risk of receiving inadequate interventions not individualized to their care needs.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 2 residents (Resident #8) reviewed for tube feedings. LVN E attempted to feed Resident #8 who was on a g-tube (a tube inserted through the abdomen directly into the stomach for feeding, fluids, or medicine when someone can't eat enough by mouth) a regular texture meal and had an order of NPO (nothing by mouth). This failure could place residents at risk for choking and aspiration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all drugs and biologicals were stored securely and had acceptable labeling for 1 of 3 medication carts (North Hall nurse medication cart) reviewed for drug storage and labeling. The facility failed to ensure expired medications, Ondansetron and Naproxen, were removed from North Hall nurse medication cart. This failure could place residents at risk of not receiving the therapeutic benefit of medication or an adverse drug reaction.

Inspectors wroteBased on interview, and record review, the facility failed to hold, safeguard, manage personal funds for 1 of 4 residents (Resident #5) reviewed for management of resident funds. The facility failed to ensure the BOM had a witness when distributing cash from the trust fund for Resident #5. The Facilities policy requires the signatures of 2 staff members when cash is dispersed to residents. The failure could place residents at risk for not having funds available when needed.

Inspectors wroteBased on interviews and facility policy review, the facility failed to ensure the individual financial record must be available to the resident through quarterly statements and upon request for 1 (Resident #1) of 5 residents reviewed for personal funds. The facility failed to provide statements of personal funds upon request. This failure could place the residents at risk of not having knowledge of the balance of their funds.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse, neglect, misappropriation of resident property, and exploitation for one of six residents (Resident #1) reviewed for abuse. The facility failed to ensure Resident #1 had the right to be free from abuse when Resident #2 physically and allegedly sexually assaulted her on 06/18/25. An IJ was identified on 06/19/25. The IJ began on 06/18/25 and removed on 06/19/25. The facility took action to remove the IJ before the abbreviated survey began. While the IJ was removed on 06/19/25, the facility remained out of compliance at a scope of isolated and severity level of potential for more than minimal harm because all staff had not been trained on resident-to-resident abuse prevention. This failure could place residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to send and receive mail, and to receive letters, packages, and other materials delivered to the facility for the resident through the means other than a postal service for 7 of 55 residents reviewed for rights to forms of communication with privacy. The facility failed to deliver mail to the resident within twenty-four hours of delivery on premises or the facility's post office box according to their policy. This failure could place residents at risk of not receiving mail in a timely manner and could result in a decline in residents' psychosocial well-being and quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public in resident bathrooms for 2 of 4 halls (100 Hall south and 100 Hall south) reviewed for environment. The facility failed to ensure floors and walls were in good repair and clean for resident bathrooms #110, #111 and #150. This failure could place residents at risk for a diminished quality of life due to the lack of a well-kept environment.

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 thaw food under proper conditions (in cooking process, in cooler, under cold running water, microwave and immediately cook afterward); not at room temperature. 2. The facility failed to ensure food items in the refrigerators were labeled with the item description and preparation date, open date, or expiration date . 3. The facility failed to ensure raw meat was stored on the bottom shelf to prevent contamination of other foods. 4. The facility failed to discard open items stored in the refrigerator and freezers that were not sealed . 5. The facility failed to ensure clean dishware was not exposed to a contaminated item . 6. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 2 of 4 shower rooms (the North and South shower rooms) and 2 of 8 resident rooms (rooms #111 and #150) reviewed for the pest control program. 1. The facility failed to ensure live roaches were not in the South Shower room and room [ROOM NUMBER]. 2. The facility had live flies observed in the North Shower room. These failures could place residents at risk for the spread of infection, cross-contamination and decreased quality of life.

Inspectors wroteBased on record reviews, and interviews, the facility failed to ensure a resident's environment remained free of accidents or hazards and received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #22) reviewed for transfers in that: 1. The facility failed to ensure CNA O provided adequate supervision and transfer assistance for Resident #22 attempting to conduct a transfer without assistance or without an assistive device. 2. The facility failed to ensure that CNAs were knowledgeable about locating the resident's safe transfer status requirements for Resident #22. An immediate jeopardy existed from [DATE] - [DATE]. The IJ was determined to be at past noncompliance as the facility had implemented actions that corrected the noncompliance prior to the beginning of the investigation. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to exercise reasonable care for the protection of the resident's property from loss or theft for 2 (Resident #13 and Resident #87) of 6 residents reviewed for resident rights. The facility failed to protect Resident #13's (2 pairs of Dickies pants, 3 pairs of Dickies coveralls, socks, and gray pant suit) and Resident #87's (2 pairs of shoes, a jacket, and a pair of shorts) clothes from being lost. This deficient practice could place residents receiving laundry services at risk of negatively impacting their quality of life and at risk for low self-esteem. Findings Included: 1. Record review of Resident #13's face sheet dated 9/18/24 revealed Resident #13 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of depression and mild intellectual disabilities. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to resolve grievances for 1 (Resident #13) of 10 residents reviewed for resident rights. The facility did not document efforts to resolve a grievance expressed by Resident #13's responsible party that stated Resident #13 was missing 2 pairs of pants, 3 overalls, 1 sweat pant suit, and 6 pairs of socks This failure could place residents at risk for feelings of worthlessness and for not receiving adequate care and services. Findings Included: Record review of Resident #13's face sheet dated 9/18/24 revealed Resident #13 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of depression and mild intellectual disabilities. Record review of Resident #13's OSA MDS assessment dated [DATE] revealed a BIMS score of 10 (suggested resident's cognition was moderately impaired) and a diagnosis of diabetes. [...]

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure resident medical records were complete and accurately documented according to accepted professional standards and practices for 1 (Resident #13) of 6 residents reviewed for medical records. The facility failed to complete Resident #13's inventory form. This failure could place residents at risk of negatively impacting their quality of life due to the loss of personal items. Findings Included: Record review of Resident #13's face sheet dated 9/18/24 revealed Resident #13 was [AGE] years old and was admitted to the facility on [DATE] with diagnoses of depression and mild intellectual disabilities. Record review of Resident #13's OSA MDS assessment dated [DATE] revealed a BIMS score of 10 (suggested resident's cognition was moderately impaired) and a diagnosis of diabetes. [...]

Inspectors wroteBased on observation, 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 food was properly stored in the facility's kitchen. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 09/18/23 at 9:49 AM revealed: - 3 tomatoes withered with white spots; - 6 red bell peppers withered and 1 red bell pepper with a brownish-black spot in a box; and - 1 bag of turkey open and exposed to air. Observation of the facility's dry storage on 09/18/23 at 9:53 AM revealed: -1 bag of macaroni pasta open and exposed to air; and -1 box of fish fry product open and exposed to air. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for 1 (Resident #205) of 6 residents reviewed for advanced directives. The facility failed to ensure Resident #205's code status was updated and documented in his physician's orders. This failure placed residents at risk of not having their end of life wishes honored.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to a safe, clean, comfortable, and homelike environment, which included but not limited to receiving treatment and supports for daily living safely for one (Resident #17) of five residents reviewed for environment. The facility failed to ensure Resident #17's walls in her room were in good repair. This failure could place residents at risk for a diminished quality of life due to the lack of a homelike environment.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the residents clinical condition demonstrated that it was not possible or the resident's preferences indicated otherwise for one of four residents (Resident #17) reviewed for weight loss and nutrition. The facility failed to ensure Resident #17 received bolus feedings as prescribed. These failures could place the residents at risk of health complication related to nutritional and hydration.

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 (CNA B) of 5 staff observed for resident care. CNA B did not wash her hands or change gloves while performing incontinent care. This deficient practice has the potential to affect residents in the facility receiving incontinent care by exposing them to care that could lead to the spread of infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, comfortable environment for residents in 1 of 1 facility reviewed for environment. The facility failed to ensure ceiling tiles were in good repair throughout the facility. These failures placed residents at risk of a decreased quality of life.

Inspectors wroteBased on record review, and interview the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for one (Resident #1) of five residents reviewed for pharmaceutical services, in that. RN A failed to administer Resident#1'sTylenol#3 (acetaminophen-codeine-schedule III ) as ordered by her physician on 08/19/2023 and 08/20/23. Resident#1 received a total of four Tylenol#3 tablets in the day, instead of three Tylenol#3 tablets. This failure placed residents, receiving medications, at risk of experiencing exacerbations of their medical conditions.