Avir at Memorial

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for two (Resident #1, Resident #2) of five residents reviewed for infection control. -The facility failed to ensure Resident #1 and Resident #2, who were on Enhanced Barrier Precautions, were protected as evidenced by nursing staff not wearing personal protective equipment during care. This failure placed all residents at risk for the spread of infections and decreased quality of life.

Inspectors wroteBased observation, interview, and record review, the facility failed to protect the resident's right to be free from neglect when (Resident #1) was not provided with goods and services to avoid harm when LVN C observed previous shift had not started feeding pump that required scheduled enteral feeding of food and water for 1 of 2 residents requiring tube feedings. -The facility failed to ensure one (Resident #1) of two residents, received required enteral food and hydration according to physician orders. This failure placed two of two residents requiring enteral food and hydration administration due to inability to orally swallow fluids, at risk of being dehydrated.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of needs and preferences for 1 (Resident #1) of 12 residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #1's room was in a position accessible to the resident on 12/02/2025. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 2 (Resident #2 and Resident #3) of 10 residents reviewed for respiratory care. The facility failed to ensure Resident #2's oxygen tubing (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored when not in use on 12/02/2025. The facility failed to ensure Resident #3's oxygen tubing was properly stored when not in use on 12/02/2025. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the medication was stored properly in locked compartments or provided a safe and secured storage with limited access for 1 (Resident #4) of 8 residents reviewed for medication storage. The facility failed to ensure a bottle of Milk of Magnesia (liquid medication used to treat constipation) was not on the nightstand next to Resident #4's bed on 12/03/2025. This failure could place the residents at risk of accidental overdose or misuse of medication.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents have the right to have reasonable access to use the telephone for 7 (Resident #30, Resident #50 and 5 anonymous residents from a group interview) of 12 residents reviewed for resident rights. 1. The facility failed to ensure there was a working phone system to receive and make calls for Resident #30, Resident #50 and 5 anonymous residents on 9/9/25 through 9/11/25. 2. The facility failed to ensure relatives of Resident #30 had a working phone number to reach the resident and facility staff. These failures could place the residents at risk of feelings of isolation and mental decline. 1. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for two of three residents (Resident #20 and Resident #54) reviewed for accident hazards/supervision/devices 1. The Facility failed to ensure CNA D used a gait belt correctly when transferring Resident #20 from his wheelchair to the bed. 2. The Facility failed to ensure Resident #54's windowsill (a ledge or sill forming the bottom part of a window) was repaired when it had the outer edge broken off exposing approximately 1 inch of raw jagged wood across the entire width of the windowsill and exposing nails. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for two (Dietary [NAME] L and Dietary Aide M) of two dietary staff reviewed for food service safety. The facility failed to ensure Dietary [NAME] L and Dietary Aide M wore effective hair restraints during lunch meal preparation on 09/10/2025. This failure placed residents at risk for food-borne illness and food contamination.

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 of 13 residents (Resident #36, Resident #14, Resident #54, and Resident #48) observed for infection control and 1 of 5 staff (CNA I) observed during meal tray delivery. 1. The facility failed to ensure LVN B sanitized the blood pressure cuff, pulse oximeter and electronic thermometer after using equipment on Resident #36 during medication pass on 09/10/25. 2. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's right to participate in the development and implementation of his or her person-centered plan of care and facilitate the inclusion of the resident and/or resident representative for 1 of 8 residents (Resident #10) reviewed for resident rights. The facility failed to ensure Resident #10's representative was offered the opportunity to participate in Resident #10's care plan meeting via telephone. This failure could place residents at risk of not being informed of resident's plan of care and a decline in quality of life.

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive care plan to meet the highest practicable physical, mental, and psychosocial wellbeing for 1 (Resident #3) of 8 residents reviewed for comprehensive care plans. The facility failed to develop and implement a comprehensive care plan for Resident #3 to address the resident's left pelvic fracture and to address Resident #3's falls. This failure could place residents at risk for not receiving care required to meet their individualized needs and place them at risk for falls 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, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 5 (Resident #39) residents reviewed for respiratory care. 1. The facility failed to ensure Resident #39's oxygen was administered at the correct setting of 2 liters per minute on 9/9/25 and 9/10/25 as ordered by the physician. This failure could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of care. Record review of Resident #39's admission record dated 10/10/25 reflected an [AGE] year-old female with an admission date of 9/11/24. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the medication error rate was not 5% or greater. The facility had a medication error rate of 6.25 %, based on 2 errors of 32 opportunities, which involved one of six residents (Residents #14) and one of three staff (LVN A) reviewed for medication errors, in that: LVN A failed to administer Resident #19's Digoxin 250 mcg with Digoxin 125 mcg for a total dosage of 375 mcg daily and failed to administer Ergocalciferol 1.25 mg on 09/10/25 as ordered by the physician. This failure could place residents at risk for not receiving therapeutic effects of their medications and possible adverse reactions.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 1 of 8 residents (Resident #7) reviewed for the storage of drugs and biologicals. The facility failed to ensure Resident # 7's Clobetasol Propionate external cream 0.05% was stored properly. This failure could place residents at risk of medication misuse, administration of incorrect dosage of medications which could result in non-therapeutic treatments or injuries.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide food that was served at an appetizing temperature, and prepared by methods which conserved the nutritive value, flavor, and appearance for one (Lunch 09/10/25) of one meals observed for food palatability. The facility failed to ensure egg salad was served at an appetizing temperature for lunch on 09/10/25. This failure could place residents at risk of food borne illness and a decline in their quality of life.

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 2 of 13 residents (Resident #1 and Resident #2) observed for infection control. 1. The facility failed to ensure RN A used the required PPE for Resident #1, who was on enhanced barrier precautions due to his wounds and foley catheter during a wound care observation on 05/20/25. 2. The facility failed to ensure Agency CNA C performed hand hygiene while providing incontinence care to Resident #2 on 05/20/25. These failures could place the residents at risk of cross-contamination and development of infection.

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 for secure unit dining room, main dining room and for 14 of 27 residents (Resident #2, Resident #39, Resident #12, Resident #13, Resident #14, Resident #17, Resident #22, Resident #25, Resident #28, Resident #34, Resident #35, Resident #43, Resident #47, Resident #48) reviewed for environment and resident rights, in that, The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior and did not ensure resident rooms were clean, sanitary and free of food debris and drink spills to prevent ants, gnats and flies. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free from pests for 16 of 26 residents (Resident #2, Resident #13, Resident #17, Resident #25, Resident #28, Resident #39, Resident#44 and 9 Confidential Group Residents) reviewed for pest control, in that: 1. The facility failed to ensure an effective pest control program was in place to keep ants out of resident rooms, resulting in 102 ant bites on Resident #2's upper middle chest, over the right breast, right side of the neck, right shoulder, right arm, and right elbow. 2. The facility failed to maintain an effective pest control to address the outside of hall 100 and hall 200 for ant activity. The facility failed to ensure resident secure unit common area windows were free of ants on 08/06/24 and 08/07/24. 3. [...]

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 for the facility's only kitchen, in that, 1. The facility failed to ensure chest freezer was free of ice accumulation. 2. The facility failed to ensure freezer items were labeled, dated and sealed. 3. The facility failed to ensure the kitchen was free of gnats and flies. 4. The facility failed to ensure steam table was not dripping. These failures could place residents at risk for food contamination.

Inspectors wroteBased on record review and interview the facility failed to implement their written policies and procedures to prohibit and prevent abuse, neglect and exploitation for 7 of the 10 employees (Activity Director, LVN AA, CNA BB, LVN DD, CNA EE, CNA FF, CNA GG) reviewed for background screenings. The facility failed to screen, through the Employee Misconduct Registry (EMR)/Nurse Aide Registry (NAR), 7 employees, which included: the Activity Director, LVN AA, CNA BB, LVN DD, CNA EE, CNA FF, CNA GG. This failure could place residents at risk of care by staff who have been reported for misconduct such as abuse, neglect, or exploitation. Findings Included: Record review of facility's Abuse, Neglect, Exploitation, or Mistreatment prohibition policy titled Leadership Policies and Procedures Section III Organizational Ethics, dated 2019, reflected: Component I: Screening 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for two of 17 (Residents #41 and Resident #39) reviewed for comprehensive care plans. 1. The facility failed to include in the care plan with an onset date of 05/29/24, Resident #41's ADLs functional limitations, Bowel incontinence and foley catheter and interventions necessary for care. 2. The facility failed to include in the care plan last revised on 07/16/24 Resident #39's contractures to bilateral hands with interventions required to prevent further decline. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure 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 of sixteen residents (Residents #41, Resident #44, and Resident #47) reviewed for ADL care. The facility failed to ensure staff provided consistent showers/baths and grooming for Resident #41, Resident #44, and Resident #47. This failure could place residents at risk of not receiving needed hygiene care which could cause skin breakdown, a loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all residents were provided, based on the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility sponsored activities and individual activities, designed to meet the interests and support the physical, mental, and psychosocial well-being of each resident for 3 of 4 residents (Residents #10, #12, and #43) reviewed for activities. The facility failed to provide regular, individualized activities for Resident #10, Resident #12, and Resident #43. This failure placed residents at risk of decreased physical, mental, and psychosocial well-being.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility were labeled and stored in accordance with professional standards for 3 of 9 residents (Resident #44, Resident #47, and Resident #30) and one of one medication room reviewed for drugs and biologicals. 1. The facility failed to ensure Resident #44's Dakins Solution (a bleach based wound cleanser) was stored properly. 2. The facility failed to ensure Resident # 47's anti-fungal powder was stored properly. 3. The facility failed to ensure Resident #30's Sevelamer carbonate blister pack (used to lower phosphate in the blood for chronic kidney disease) was labeled with the correct dosage. 4. The facility failed to remove expired medication from the medication room refrigerator. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure proper treatment and assistive devices to maintain hearing abilities for one of one resident (Resident #13) reviewed for hearing devices. The facility failed to have Resident #13 assessed for his hearing loss and failed to provide any amplification device to assist with his hearing impairment. This failure could place residents at risk for limited social interactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents receive adequate supervision and assistance devices to prevent accidents for one of two residents (Resident #13) reviewed for assisted transfers The Facility failed to ensure NA J used a gait belt when transferring Resident #30 from his wheelchair to the bed. These failures could affect the residents by placing the residents at risk for discomfort, pain, falls, injuries, and skin tears.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for one of three residents (Resident #41) reviewed for catheter and incontinence care. The facility failed to ensure CNA I did not place the urine catheter drainage bag on the bed during Resident #41's incontinent care, and wound dressing change. The facility failed to ensure CNA I did not perform hand hygiene during Resident #41's incontinent care. These failures could place residents at risk for not receiving care appropriate to address their incontinence and could increase the risk of urinary tract infections.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide treatment and services to prevent complications of enteral feeding for one of three residents (Residents #39) reviewed for feeding tubes. The facility failed to ensure staff followed physician ordered water flushes before and after medication administration given via the G-Tube for Resident #39. These failures could place residents at risk of tube obstruction and a decrease in hydration.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents who required dialysis received such services, consistent with professional standards of practice for one of 2 residents (Resident #30) reviewed for dialysis. The facility failed to ensure post dialysis communication sheets were reviewed and completed for Residents #30. This failure could place residents at risk of inadequate post dialysis care.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 4 (Resident #23, Resident #44, Resident #49, and Resident#24) of 16 residents reviewed for ADLs. The facility failed to ensure: 1- Resident#23 had her fingernails cleaned and trimmed. 2- Resident#43 had her fingernails cleaned and trimmed. 3- Resident#49 had his fingernails cleaned and trimmed. 4- Resident#24 had her facial hair under her chin trimmed These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that based on the comprehensive assessment of a resident, the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan for one (Resident #56) of fifteen residents reviewed for quality of care. 1. The facility staff failed to obtain physician orders for the use of compression socks for Resident #56. 2. The facility staff failed to perform weekly skin assessments for the month of June 2023 for Resident #56. These failures could place residents at risk of not receiving the care and treatment needed to meet their needs and could result in undetected skin issues and delay in treatments.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for the facility's only kitchen reviewed for one (06/21/23 lunch) of one meal observed for food temperatures. The facility failed to ensure pureed ham was served at minimum of 145 degrees F and cabbage was served at least 135 degrees F for 06/21/23 lunch for residents with pureed diet. This failure could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for the dining room and one of four halls (Hall 3) reviewed for pest control. The facility failed to keep an effective pest control program to ensure the dining room, kitchen, and residents' rooms on Hall 3 were free of flies and gnats. This failure could place residents at risk for a reduced quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the comprehensive care plan described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for one (Residents #56) of fifteen residents reviewed for comprehensive care plans. The facility failed to document Resident #56's use of compression stockings in his comprehensive care plan. This failure could place residents at risk for possible adverse side effects, adverse consequences, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate acquiring and administering of all medications to meet the needs of each resident for two (Residents #15 and #58) of four residents reviewed for pharmacy services. 1. Agency LVN A failed to follow the manufacturer's instructions to [NAME] the Humalog Insulin (Hormone) Pen prior to dialing in required amount of Insulin to be administered to Resident #15. 2. Agency LVN A failed to flush Resident #58's G-Tube (a tube inserted through the abdomen that delivers nutrition directly to the stomach) with 60 cc water prior to and after medication administration per physician orders and failed to flush the G-tube by gravity, and instead pushed 50 cc of water prior to and after medication administration. [...]

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 one (Resident #15) of five residents observed for infection control in that: 1. The facility failed to ensure Agency LVN A performed hand hygiene after completion of FSBS 2. The facility failed to ensure Agency LVN A failed to sanitize the glucometer prior to and after obtaining FSBS on Resident #15. Theses failure could place residents at risk for infection and cross contamination.