Avir at Orem

Inspectors wroteBased on record review and interview, the facility failed to transmit accurate, encoded, complete MDS assessments to the CMS system within 13 days for 4 of 18 residents records reviewed for MDS transmission (Residents # 2, 6, 13). -The facility failed to ensure that Resident #2's, annual MDS assessment dated [DATE] was transmitted within 14 days -The facility failed to ensure that Resident #6's, annual MDS assessment dated [DATE] was transmitted within 14 days -The facility failed to ensure that Resident #13's, annual MDS assessment dated [DATE] was transmitted within 14 days These failures put residents at risk of not having their assessments completed timely which could result in denial of services or denial of payment for services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare and distribute food in accordance with professional standards for food safety in that - The facility failed to ensure that the vVent hood above the stove was free of grease build up. The facility failed to ensure that frozen meat was properly thaw under running These failures placed residents at risk of foodborne illness and accident.

Inspectors wroteBased on interviews and record review, the facility failed did not implement policies and procedures to ensure the resident's medical record includes documentation of receiving or refusal of influenza or pneumococcal immunization for 5 of 6 residents reviewed for immunizations (Resident#2, Resident #3, Resident #11, Resident #60, and Resident #84). The facility failed to implement their influenza and pneumococcal immunization policies to document evidence in the electronic medical record the offering or the refusal of the influenza and pneumococcal immunization status for Resident #2, Resident #3, and Resident #11. The facility failed to implement their pneumococcal immunization policy to document evidence in the electronic medical record the offering or the refusal of the pneumococcal immunization status for Resident #60 and Resident #84. [...]

Inspectors wroteBased on interview and record reviews, the facility failed to develop and implement policy and procedures to ensure residents were offered, received, or refused the Covid-19 immunization, for 5 of 6 residents (Resident #2, Resident #3, Resident #11, Resident #60 and Resident #84) who were reviewed for immunization compliance. The facility failed to develop a Covid-19 immunization policy that addressed the documentation in Resident #2, Resident #3, Resident #11, Resident #60 and Resident #84's electronic medical records for having received or not receiving the Covid-19 immunization due to medical contraindication or refusal. This failure could place residents at risk of not being informed of complications and potential adverse health outcomes. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan with measurable objectives and timetable to meet the resident's medical, nursing, and psychosocial needs that were identified in the comprehensive assessment for 1 of 18 residents reviewed for care plans (Resident # 105). --Resident # 105 did not have a care plan for ADLs. This failure placed residents at risk of not having their needs identified and addressed. [...]

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 #2) reviewed for mental illness, disability, or developmental disability. The facility failed to ensure Resident #2, who had a positive PL1, had a PL2 completed. This failure could place residents at risk of mental health needs not being met. Record review of Resident #2's face sheet, dated 5/6/2026, revealed a [AGE] year-old male who was admitted to the facility originally on 11/18/2020 and readmitted on [DATE]. Resident #2 had diagnoses which included Cerebral infarction (the most common type of stroke; [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 24 residents (Resident #51) reviewed for significant medication errors. The facility failed to ensure Metoprolol (a blood pressure (BP) medication given to lower high blood pressure) was administered six times in March 2025 to Resident #51 as ordered on 02/26/2025 by the physician and Resident #51 was administered Metoprolol 12.5 mg outside of physician set parameter of the residents SBP (the top BP number) less than 100 hold. This failure could place residents at risk of not receiving desired therapeutic outcomes, increased side effects, or a decline in health.

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 1 of 24 residents (Resident #40) reviewed for infection control practices. The facility failed to ensure CNA C followed proper infection control, glove changes and hand hygiene for Resident #40 during incontinent care. CNA C failed to use a clean wipe, change gloves and perform hand hygiene during incontinent care. This failure could place residents at risk of infection or a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source, are reported immediately, but no later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events do not result in serious bodily injury, to the Administrator of the facility and to other officials (including to the State Survey Agency) in accordance with state law through established procedures for 1 (Resident #1) of 7 residents reviewed for abuse. CNA A failed to immediately notify the Administrator on 09/03/24 Resident #1 had bruising on the right arm of unknown origin. This failure could place residents at risk for abuse and neglect. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to provide the necessary services to maintain good personal hygiene to a resident who is unable to carry out activities of daily living for one of five residents (Resident #2) reviewed for ADL care. The facility failed to provide Resident #2, who required extensive assistance, with timely incontinence care on 02/25/25 from 6:30 a.m. to 11:30 a.m. This failure could place residents at risk of skin breakdown, urinary tract infections and loss of dignity.

Inspectors wroteBased on 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 includes measurable objective and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #1) reviewed for care plans. -The facility failed to ensure Resident #1's treatment orders for Right Heel Unstageable DTI were followed as ordered by the physician on 12/18/24 . -Wound Care Nurse documented administering a treatment to Resident #1's Right Heel Unstageable DTI that she did not provide on 12/18/24 . These deficient practice could affect residents with comprehensive care plans and could result in missed or delayed continuity of care.

Inspectors wroteBased on observations, interviews, 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 infection for 1 of 3 residents (Resident #1) reviewed for infection. -The facility failed to ensure Wound Care Nurse performed hand hygiene after removing soiled gloves and before applying new gloves while providing Resident #1's wound care on 12/18/24. -The facility failed to ensure Resident#1's wounds were covered after evaluation from the wound care physician on 12/18/24. These failures could place residents at risk for the spread of infection.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident has the right to access personal and medical records pertaining to himself and allow the resident to obtain a copy of the records upon request and upon two working days advance notice to the facility for 1 of 2 residents (CR#1) whose records were reviewed in that: - The facility failed to provide CR#1's Responsible party copies of medical records after a request was submitted to the facility on [DATE]. This failure could place residents at risk of violation of their rights by not receiving copies of their medical records.

Inspectors wroteBased on observation, interview and record reviews the facility failed to ensure a resident that was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming and personal and oral hygiene for 1 of 4 (Resident #1) reviewed for Activities of Daily Living. The facility failed to ensure Resident #1's adult brief was checked and changed when needed. This failure could affect all residents that required staff assistance with activities of daily living and could result in poor hygiene and skin breakdown. Findings Included: [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that residents who require dialysis received such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 6 residents (CR #1) reviewed for dialysis. The facility failed to ensure CR #1 received hemodialysis since she admitted to the facility on [DATE]. CR #1 missed dialysis on Saturday 2/10/24 and Tuesday 2/13/24. CR #1 was sent to the hospital on 2/14/24 with signs of altered mental status, increased confusion, and lethargy. The facility failed to document monitoring of CR #1's dialysis port (access site used when blood is transported from the body for cleaning) The facility failed to obtain a signed contract with CR #1's dialysis center. An immediate jeopardy (IJ) was identified on 2/16/24 at 12:26 p.m. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the environment remained as free of accident hazards as is possible for 3 of 7 residents' rooms (Resident #84, Resident #80, and Resident #33) reviewed for accidents. -The facility failed to maintain water temperatures at a safe temperature level in Resident #84, Resident #80, and Resident #33's bathrooms. This failure could place residents at risk of injuries and burns.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure comprehensive care plans were reviewed and revised by the Interdisciplinary Team after each assessment for 2 (Resident #35 and Resident #30) out of 18 residents reviewed for care plan accuracy. -The facility failed to update Resident #35's comprehensive care plan to include an updated BIMS score and removal of the left hand posey (something to grip to help prevent contractures) and the right-hand carrot (something to grip with a severe hand contracture). -The facility failed to update Resident #30's comprehensive care plan to include the oxygen she was using and remove the finger extension brace (splint worn for contracture management in the fingers) and the hand splints (splint worn to protect joints by positioning correctly) which were not being used. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 1 of 1 Resident (#56) reviewed for oxygen in that: -Resident #56's oxygen was administered at 3 Liters Per Minute instead of 2 Liters Per Minute via nasal cannula as ordered by the physician. This deficient practice could affect Resident #56 who received oxygen continuously and could result in residents receiving incorrect or inadequate oxygen support and could result in a decline in health.

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 of each resident on one of two medication carts (the 100/300/400 nurse cart) reviewed for pharmacy services. -The facility failed to account for 53 of CR #1's Oxycodone-Acetaminophen tablets. - Staff failed to document the administration of narcotic medications in a correct manner for CR #1. This failure could place residents at risk for drug diversion and delay in medication administration.