Avir at Magnolia

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents had the right to be free from physical abuse and neglect for two (Resident #1 and Resident #2) of five residents reviewed for abuse and neglect. 1. The facility failed to ensure Resident #1 was not physically abused by CNA A, on an unknown date, and witnessed by NA B and NA C, when CNA A put soap in Resident #1's eyes in the shower room.2. The facility failed to ensure Resident #2 was not physically abused by CNA A, on an unknown date, and witnessed by NA B and NA C, when CNA A physically restrained Resident #2 in his room while providing peri-care. The noncompliance was identified as PNC. The IJ began on 09/26/2025 and ended on 10/13/2025. The facility had corrected the noncompliance before the survey began on 10/14/2025. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that alleged violations involving abuse were reported immediately, but not later than 2 hours after the allegations are made to the abuse coordinator for two (Resident #1 and Resident #2) of five residents reviewed for abuse. The facility failed to notify the abuse and neglect coordinator (ADM) of the alleged abuse by CNA A towards Resident #1 and Resident #2 so it could be investigated and handled appropriately to ensure the residents' safety. The noncompliance was identified as PNC. The IJ began on 09/26/2025 and ended on 10/13/2025. The facility had corrected the noncompliance before the survey began on 10/14/2025. These failures could place residents at risk of abuse, neglect, trauma, and psychosocial harm.

Inspectors wroteBased on interview and record review the facility failed to, in response to allegations of abuse, neglect, exploitation, or mistreatment, have evidence that all alleged violations are thoroughly investigated and report the report the results of all investigations to the state survey agency within five working days of the incident for two of five residents (Resident #1 and Resident #2) reviewed for abuse and neglect. The facility failed to thoroughly investigate two allegations of abuse regarding Resident #1 and Resident #2 to identify a timeframe of when alleged abuse occurred and failed to notify the local law enforcement. This deficient practice placed residents at risk of abuse due to not having a thorough investigation done for facility reported incidents.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 4 of 10 residents (Resident #2, Resident #25, Resident #40, and Resident #66) reviewed for rights. The facility failed to ensure CNA D and HK F knocked on Resident #2, Resident #25, and Resident #40's doors when going into the residents' rooms. The facility failed to provide Resident #66 with a privacy bag for his catheter. These failures could place residents at risk of feeling like their privacy was being invaded or could have a negative psychosocial, psychosocial harm and emotional distress.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure food was properly labeled and dated. The facility failed to maintain proper kitchen sanitation when [NAME] B, did not follow proper hand hygiene protocols. These deficient practices could place residents who were served from the kitchen at risk for health complications and foodborne illnesses.

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 4 (Resident #7, Resident #75, Resident #49 and Resident #2) of 8 residents reviewed for infection control practices, in that: The facility failed to:1. Ensure CNA E changed dirty gloves when handling clean items while providing peri care to Resident #7 and Resident #75.2. Ensure MA D sanitized blood pressure monitor in between Resident #49 and Resident #2 while obtaining blood pressure. 3. Ensure MA D had not stored her orange juice in use, in the med cart at the facility. This failure could place residents at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased on interview and record review, the facility admitted a resident with a mental disorder before the Stated mental health authority had determined she was appropriately placed for 1 of 1 resident (Resident #9) reviewed for PASARR screening. The MDS Coordinator failed to complete the PASARR screening process for Resident #9. This failure could place residents at risk of not receiving specialized services.

Inspectors wroteBased on observation, interview, and record review, the facility failed develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet a residents' mental, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for 1 of 8 Residents (Resident #3) reviewed for care plans. The facility failed to care plan Resident #3's dialysis that he received 3 times a week from an external dialysis center. This failure could lead to residents on dialysis receiving improper care/treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #66 and Resident #8) of 4 residents reviewed for catheter care. The facility failed to ensure Resident #66 and Resident #8's catheters' drainage bag positioned lower than Resident's urinary bladder to prevent urine from flowing back into the kidneys and urinary bladder. This failure could place residents at risk of UTI and other serious infections.

Inspectors wroteBased on interviews, 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 2 of 58 days (08/09/2025 and 08/10/2025) reviewed for RN coverage. The facility failed to ensure they had an RN scheduled on duty for 08/09/2026 and 08/10/2025 and failed to ensure the DON was not acting as the charge nurse when the facility had an average daily occupancy of more than 60 residents. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatment.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure drugs and biologicals were stored in locked compartments for 1 of 3 medication carts (100 hall) reviewed for medication storage. The facility failed to ensure the medication cart for 100 hall was locked when unattended by LVN A on 08/26/2025 at 12:37p.m. These failures could place residents at risk of harm due to unauthorized access and potential ingestion of medication, needles, and other biologicals.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. NA A failed to have another staff assist while providing a mechanical lift transfer for Resident #1 from chair to bed on 07/09/2025. Resident #1 fell out of the mechanical lift, fell to the floor hitting her head, was transferred to the ER and was diagnosed with a laceration to the back of her head that required staples. The noncompliance was identified as past noncompliance. The IJ began on 07/09/25 and ended on 07/10/25. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 of 3 residents (Resident #1) reviewed for accidents and supervision, in that:The facility failed to ensure Resident #1, who ambulated with the help of a walker, received adequate supervision to prevent him from exiting the facility with a busy highway at the front, undetected on 06/09/25. The non-compliance was identified as Past Non-Compliance. The Immediate Jeopardy (IJ) began on 06/09/25 and ended on 06/11/25. The facility corrected the non-compliance before the investigation began on 06/25/25. This failure could place the residents with exit seeking behaviors at risk for injury or death.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medications errors for one of one (Resident #1) of three residents reviewed for significant medication errors. The facility failed to ensure Resident #1 was administered her prescribed Bactrim (antibiotic) until seven days after receiving positive UTI results on 04/11/25, causing her to be in increased pain and dysuria (pain with urination). This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to promptly notify the ordering physician or nurse practitioner of laboratory results that fall outside of clinical reference ranges in accordance with facility policies and procedures for notification of a practitioner or per the ordering physician's orders for 1 (Resident #1) of three residents reviewed for laboratory services. The facility failed to ensure Resident #1 was administered her prescribed Bactrim (antibiotic) until seven days after receiving positive UTI results on 04/11/25, causing her to be in increased pain and dysuria (pain with urination). This failure could place residents at risk of not receiving the intended therapeutic benefit of the medications and supplements or could result in worsening or exacerbation of chronic medical conditions.

Inspectors wroteBased on interview and record review, the facility failed to immediately inform the resident, consult with the resident's physician when there was a significant change in the resident's physical, mental, or psychosocial status for one (Resident #1) of four residents reviewed for resident rights. The facility failed to notify the facility MD when Resident #1 was experiencing shortness of breath and chest pain on 02/28/25. This failure could place residents at risk of illness, injury, uncontrolled pain, and a decreased quality of life.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 5 residents (Resident #1) reviewed for dietary services. The facility failed to follow Resident #1's altered diet when CS A gave Resident #1 a peanut butter sandwich on 08/15/2024. Resident #1 expired on 08/15/2024. An Immediate Jeopardy (IJ) situation was identified on 08/28/2024. While the IJ was removed on 08/29/2024, the facility remained out of compliance at no actual harm with potential for more than minimal harm that is not immediate jeopardy, due to the facility's need to evaluate the effectiveness of the corrective systems. This failure could place residents at risk of not receiving their proper diet to meet their individual needs, that can cause serious injury, hospitalization, or death. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure menus and nutritional adequacy met the nutritional needs of residents in accordance with established national guidelines for 2 of 2 observed meals reviewed for meal accuracy. The facility failed to ensure there was 7 days' worth of food available from 07/31/2024 through 08/06/2024 to prepare and serve their planned and/or alternate menu on 08/06/2024 for lunch and dinner. This deficient practice could place residents at increased risk for inadequate nutrition .

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 safety for 1 of 1 kitchen reviewed for food safety and sanitation. The facility failed to ensure food that was prepped was labeled and dated. The failure placed residents at risk of foodborne illness.

Inspectors wroteBased on record review and interview, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with a PASRR Evaluation assessment for 1 of 5 residents (Resident #32) reviewed for PASRR screening, in that: The facility did not have an accurate PASRR Level 1 assessment for Resident #32 when he had a diagnosis of major depressive disorder and mood disorder unspecified which would have triggered Resident #32 for a positive assessment for mental illness. This failure could place residents with an inaccurate PASRR Level 1 evaluation at risk for not receiving care and services to meet his needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to 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 of 3 newly admitted residents (Resident #128) reviewed for baseline care plan. The facility did not create a baseline care plan for Resident #128 upon admission. This failure could place residents at-risk for decreased quality of life, improper care, and injury.

Inspectors wroteBased on observation, interviews, 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 six of eighteen (Resident # 21, and Resident #40) residents reviewed for ADL's. The facility failed to ensure Resident # 21 and Resident #40's nails were cleaned, received a shower during the time period of 07/09/2024 thru 07/14/2024 and remove Resident #40's facial hair on her chin and above her upper lip. These failures placed residents at risk of a decline in their hygiene, at risk of skin breakdown, loss of dignity and decline in quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident, encouraging both independence and interaction in the community for 2 of 10 residents ( Resident # 48 and Resident #50) reviewed for activities. 1. The facility failed to develop an activity program based on preferences of Resident #48 and Resident #50. 2. The facility failed to provide activities as scheduled on July 6th-July 7th, July 13th, and July 14th. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's environment remains as free of accident hazards as is possible for 1 of 24 residents (Resident #53) whose care was reviewed for accidents and hazards in that: Resident #53 was observed with a 12-ounce aerosol air freshener bottle at the bedside. Resident #53 had a diagnosis of Asthma and Oxygen therapy, both of which contraindicated use of aerosols. This failure could affect residents and place them at risk of contributing to avoidable accidents and injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who needed respiratory care were provided such care, consistent with professional standards of practice, for 2 of 3 residents (Residents #24 and #30) reviewed for oxygen in that: The facility failed to ensure Resident #53's oxygen humidifier, tubing, and cannula were changed, dated, and initialed according to facility policy. The facility failed to ensure Residents #53's tubing was clean , changed weekly and initialed or signed. This failure could affect residents who received oxygen by placing them at risk for respiratory infections.

Inspectors wroteBased on observation, 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 to each resident for one (Resident #58) of four residents reviewed for medications. The facility failed to ensure Resident #58 was administered anti-acid medications without a physician order and to ensure the resident swallowed the medication prior to leaving the resident's room. This deficient practice could place residents at risk of consuming unprescribed medications, harm, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to provide sufficient support personnel with the appropriate competencies and skills sets to carry out the functions of the food an d nutrition service, taking into consideration resident assessments, individual plans of care and the number, acuity and a diagnoses of the facility's resident population in accordance wit the facility assessment for one of one kitchen staff (Dietary Aide H) reviewed for qualified dietary staff. The facility failed to ensure the Dietary Aide H received orientation and training prior to beginning work in the kitchen. This failure could place the residents at risk for the spread of food borne illness and residents not having their nutritional needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for three (Resident #1, Resident #2, and Resident #3) of five residents reviewed for personal hygiene. The facility failed to provide nail care for Resident #1, Resident #2, and Resident #3. This failure could place residents at risk of injury, infection, and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an effective pest control program to keep the facility free of pests for the 1 of 1 kitchen, 1 of 1 dining room, and 2 of 6 hallways. The facility failed to treat the flies in the building. This failure could place all residents at risk of cross-contamination, infection, foodborne illness, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for 4 residents out of 10 residents (Resident #29, Resident #67, Resident #135, and Resident #53) reviewed for Activities of Daily Living care. The facility failed to provide nail and/or hair care to Residents #29, #67, #135 and #53. This deficient practice placed residents at risk of a decline in their hygiene, at risk of skin breakdown, a decreased level of satisfaction with life, and a decreased feeling of self-worth.

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 of transmission of communicable diseases and infections for 3 of 4 residents (Residents 17, 49 and 14) reviewed for infection control. 1. LVN A failed to practice appropriate hand hygiene and infection control techniques during wound care for Resident #17. 2. CNA E and CNA F failed to practice appropriate hand hygiene and infection control techniques during incontinent care for Resident #49 and Resident #14. This failure could put residents at risk for infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible for five of six halls (halls 100, 200, 300, 400, and 600) reviewed for cleanliness. The facility handrails in halls 100, 200, 300, 400, and 600 were sticky to the touch. This failure placed residents at risk of discomfort and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the confidentiality of personal health care information for 2 of 15 [Resident #58 and Resident #49) residents reviewed for confidentiality of records. The facility failed to protect the private healthcare information of Residents # 58 and #49. These failures could affect residents by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on observation, 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 for one of seven residents (Resident #72) reviewed for PASRR services. The facility failed to refer Resident #72, who had bipolar disorder, to the LMHA for a Level II PASRR evaluation. The failure placed residents at risk of going without treatment for mental illness.

Inspectors wroteBased on observation, interview, and record review the facility failte failed to ensure respiratory care was provided consistent with professional standards of practice for two of two residents (Residents 17 and 63) reviewed for respiratory care. 1. The facility failed to ensure proper tracheostomy care was provided to Resident # 17. 2. The facility failed to ensure a nebulizer mask was put in a bag after use for Resident # 63. The failure could place residents who receive respiratory care at risk for respiratory infection.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were stored properly for 1 of 1 Medication Aide carts reviewed for drug storage. The medication aide cart had an open can of a caffeinated energy drink, a large bag of cheese flavored puffs and a bottle of water from an island aquifer in drawers with over-the-counter medications This failure placed residents at risk of receiving contaminated medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility for one of one survey results binder reviewed for posting. The facility failed to include the results of the last standard survey dated 03/17/22 in the posted survey results binder. This failure place residents at risk of not being aware of the facility status/findings of the most recent standard survey.