Avir at Meadow Creek

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 2 (Residents #7 and #13) of 4 residents observed for oxygen management. The facility failed to ensure Oxygen (O2) in use signage was on the doorways of Resident #7 and Resident #13. This failure could place residents at risk of not receiving appropriate respiratory care.

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. The facility failed to: Ensure the multi-juice dispenser spigot (a faucet) was cleaned. This failure could place residents at risk of foodborne illnesses.

Inspectors wroteBased on interviews and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 1 (Resident #38) of 7 residents reviewed for advance directives. The facility failed to ensure Resident #38's advance directive was clearly identified and documented in the resident's electronic medical record. The failure could place residents at risk of not having their end-of-life wishes honored and having incomplete records.

Inspectors wroteBased on observation, interview, and record review the facility failed to post the daily nurse staffing information with the current date, resident census, and numbers of staff actual hours worked at the beginning of each shift for 1 of 1 facility reviewed for nurse staffing. The facility failed to update and post the daily nurse staffing information from 6/2/2026 through 6/10/2026. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding the numbers of staff caring for the residents each shift and the facility census.

Inspectors wroteBased on interview and record review the facility failed to ensure that each resident received adequate supervision and assistive devices to prevent accidents for 1 of 5 resident (Resident # 1) reviewed for transfers. The facility failed to ensure LVN C utilized a gait belt to transfer Resident #1 while toileting which resulted in a right dislocated shoulder. This failure could place residents at risk for falls, injury and a diminished quality of life.

Inspectors wroteBased on interviews and record review the facility failed to develop a baseline care plan within 48 hours of admission that included instructions needed to provide effective and person-centered care of the resident that met professional standards of quality of care for 1 of 5 residents (Resident #1) reviewed for baseline care plans. The facility failed to develop the baseline care plan for Resident #1 within 48 hours following his admission on [DATE]. This failure could place residents at risk for complications due to the potential for their immediate needs not being identified so interventions could be planned and initiated.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 of 3 residents (Resident #1) reviewed for pressure ulcer treatment. The facility failed to ensure Resident #1's wound care treatments were implemented according to physician orders and wound care recommendations. This failure could place residents at risk of delayed wound healing, increased risk of infection, and further skin breakdown.

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 service safety in 1 of 1 kitchen reviewed for kitchen sanitation. 1. The facility failed to ensure stored foods were properly stored, labeled, and dated. 2. The facility failed to ensure prepared food was discarded after 72 hours (3 days) per facility policy. 3. The facility failed to check temperatures of food items prior to serving food. 4. The facility failed to ensure food was not handled with bare hands. 5. The facility failed to ensure food items remained covered on the steam table prior to food service between breakfast and lunch. 6. The facility failed to ensure personal food items were not stored in 1 of 2 of the kitchen refrigerators. 7. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 2 of 2 residents (Resident #10 and #11), 2 of 2 residents who used a mechanical lift in the resident council meeting, and one unsampled resident reviewed for the mechanical lift. The facility failed to have sufficient mechanical lift slings to accommodate all residents who required the use of a sling (Resident #10, Resident #11, two residents in the resident council meeting). These failures could place residents at risk of a diminished quality of life due to an environment that is nonfunctional or uncomfortable.

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 to help prevent the development and transmission of communicable diseases and infections for one (Resident #41) of two residents reviewed for transmission-based precautions care in that: 1. CNA G failed to wear required PPE when entering Resident #41's room on 04/08/2025. 2. HSK H failed to wear required PPE when entering Resident #41's room on 04/09/2025. 3. CNA I failed to wear required PPE when entering Resident #41's room on 04/10/2025. This failure could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 13 residents (Resident #20 and 41) reviewed for care plans. There was no care plan addressing Resident #20's use of a gait belt across his wheelchair. There was no care plan addressing Resident #41's isolation status. This failure could affect the resident by placing them at risk for not receiving care and services to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being.

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 for 1 of 3 residents (Resident #20) reviewed for accidents and hazards: The facility failed to ensure Resident #20 was thoroughly educated about the risks associated with strapping himself into his wheelchair with a gait belt (device typically used by aides as a transfer aide for more dependent resident to prevent falls). This failure could place residents at risk of harm or injury and contribute to avoidable accidents and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive, person-centered care plan for each resident that included measurable objectives and time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 5 residents (Resident #4 and Resident #5) reviewed for care plans. 1. The facility failed to ensure that Resident #4 had a care plan in place for his use of diuretic medication. 2. The facility failed to ensure that Resident #5 had a care plan in place for her use of diuretic medication. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to protect residents' rights to formulate an advance directive for 1 (Resident #161) of 17 residents reviewed for advanced directives. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. Resident #161 had chosen Do Not Resuscitate status. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident had the right to be free from neglect for 1 of 17 (Resident #161) residents reviewed for neglect. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to implement written policies that prohibit abuse and neglect for 1 of 17 (Resident #161) residents reviewed for neglect. The facility failed to ensure there was a system in place to assess code status adequately and accurately during the admission process after regular business hours, on weekends, and on holidays, resulting in Resident #161's code status not being assessed correctly during her admission to the facility on hospice services [DATE] at 8:00 pm. This failure also resulted in Resident #161's code status remaining listed as Full Code when she became unresponsive on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility personnel failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders follow physician orders and the resident's advance directives for 1 of 6 residents (Resident #161) whose records were reviewed for Full code status. The facility failed to ensure that nursing staff provided Resident #161, who was listed as a Full Code, CPR, after the resident was reported to LVN C as not breathing, according to professional standards of practice. LVN C failed to verify Resident #161's code status before calling hospice which led to the resident being pronounced dead and CPR not being initiated for approximately 63 minutes after the resident was found to be unresponsive. An Immediate Jeopardy (IJ) was identified on [DATE] at 3: [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the resident's had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred, for 3 of 20 residents (Resident #34, Resident # 47, Resident#260) reviewed for resident rights . The facility failed to obtain informed consent based on information of the benefits, risks, and options available from Resident #34 prior to administering Zoloft, an antidepressant used to treat depression. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services, including procedures that ensure the accurate administering of all drugs to meet the needs of the residents, for 1 (hall 100 medication cart) of 2 medication carts inspected for medication storage. The hall 100 medication cart had expired medications and wound care supplies. This failure could place residents at risk of receiving medications that were expired and not produce the desired effect.

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 safety in the facility's only kitchen. The facility failed to ensure food items in the facility's only dry storage were dated and sealed appropriately. These failures could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observations, interview and record review the facility failed to establish and maintain an infection prevention and control program to help prevent the development and transmission of communicable infections for 1 of 3 residents (Residents #1) reviewed for infection control, in that: LVN B failed to change her gloves after they became contaminated during incontinent care while assisting Resident #1. LVN B failed to wash or sanitize her hands prior to putting on gloves and after removing them during incontinent care while assisting Resident #1. These failures could place residents at risk of urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure at the time each resident was admitted , the facility had a physician order for the resident's immediate care for 1 (Resident #1) of 2 residents reviewed for residents receiving necessary care and services upon admission. The facility failed to follow physician orders for Resident #1 to be non-weight bearing to right foot. As a result, Resident #1 had right leg amputated just below knee. An Immediate Jeopardy (IJ) was identified on 12/22/2023. While the IJ was removed on 12/23/23 at 4:30p.m, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice for one 1 (Resident #1) of 2 residents reviewed for quality of care. The facility failed to ensure staff followed Resident #1's physician's orders by wound care physician for non-weight bearing when ambulating which led to Resident #1 having a below the knee amputation. An Immediate Jeopardy (IJ) was identified on 12/22/2023. While the IJ was removed on 12/23/23 at 4:30p.m, the facility remained out of compliance at a severity level of actual harm, and a scope identified as pattern due to the facility's need to complete in-service training and evaluate the effectiveness of the corrective actions. This failure could place residents at risk of not receiving adequate care and services, and decreased quality of life.