Avir at Park Bend

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident 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 and neglect. The facility failed to prevent CNA A from mistreating Resident #1. CNA A verbally abused Resident #1 while providing care for her on 06/21/2026 at 8:19 p.m. This failure could place all residents who received care from CNA A at risk of staff mistreatment.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy during personal care for 1 of 3 residents (Resident #1) reviewed for privacy. The facility failed to ensure CNA A provided privacy by closing the door and drawing the privacy curtain during incontinent care for Resident #1. This failure could place residents at risk of lack of privacy and not having residents' rights acknowledged.

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 residents' goals and preferences for 2 of 4 residents (Resident #2 and Resident#3) reviewed for respiratory care. The facility failed to ensure the nebulizer masks and tubing of Resident #2 and Resident #3 were stored safely in protective bags. This failure placed residents at risk for respiratory infections through contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident has a right to personal privacy and confidentiality of his or her personal and medical records for 1 (Resident #1) of 29 residents on 300 Hall reviewed for Privacy and Confidentiality. The facility failed to ensure Resident #1's personal health information was protected from being viewed by unauthorized person when the RN left Resident #1's personal information displayed on the computer screen located at the charting station on 300 Hall while unattended. This failure could place residents' personal information at risk of being exposed to unauthorized individuals.

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 and sanitary environment to prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) reviewed for infection control. Facility staff failed to recognize infection control protocol for EBP and Contact precautions for Resident #1. The facility failed to ensure CNA C disinfected the mechanical lift before taking it out of Resident #1's room. The facility failed to ensure CNA C put on a gown and conduct handwashing/hand hygiene between glove changes when providing peri-care to Resident #1 These failures could place the residents at risk of infection transmission, poor wound healing, and hospitalization.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure 1 (Resident #2) of 4 residents reviewed for Resident Rights was treated with respect and dignity. Resident #2 stated she felt that she was being labeled here for being bipolar. Resident #2 stated she had been getting high anxiety all over her body, had a lot of crying, and she had been picking at a place on her chin to [NAME] come and could not stop. Resident #2 said she felt as if it was her responsibility to speak in Spanish to MA E to show her respect since that was MA E's preferred language. These failures can lead to residents feeling like their rights were not being respected.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services which includes the accurate acquiring, receiving, dispensing and administering of medications to meet the needs for one resident (Resident #1) of 4 residents reviewed for pharmacy services, in that: MA failed to correctly administer a lidocaine patch medication to resident on 8/15/2025 at 11:03 AM. This failure placed residents at risk for medical errors, complications, decreased quality of life and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure 1 (Resident #1) of 5 residents had the right to be treated with respect and dignity. CNA A did not provide Resident #1 with a shower when he asked to be assisted with a one. This failure placed the residents at risk of not receiving the care and services to meet their needs, and therefore not respecting their dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 5 residents (Resident #1) observed for infection prevention. The facility failed to ensure enhanced Barrier Precautions (EBP) were implemented when CNA A & CNA B provided peri and colostomy care to Resident #1. This deficient practice could place the residents at risk for the spread of infection.

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 1 (Resident #19) of 5 residents and 3 (100 Hall MC 200 Hall MC and 300 Hall MC) of 8 medication carts reviewed for pharmaceutical services. A total of 29 loose pills were observed in 100 Hall MC 200 Hall MC and 300 Hall MC A total of 3 medications were observed as expired in 100 Hall MC 200 Hall MC and 300 Hall MC These failures could place residents at risk of not receiving all their prescribed medications, which could exacerbate their illness, and expired medications could have a decrease in effectiveness or make the resident sick.

Inspectors wroteBased on interview and record review, the facility failed to provide accurate PASRR screenings for individuals with a mental disorder for 1 (Resident #72) of 6 residents reviewed for PASRR. The facility failed to complete an accurate PASRR level one screening after Resident #72 was admitted with a negative PASRR Level 1 screening but had a mental illness. This failure could place residents at risk of not receiving or benefiting from specialized therapy and equipment services they may require.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident that described the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 10 (Resident #44) residents reviewed for care plans. The facility failed to update the care plan for Resident #44 to reflect how to meet the needs of the resident when a gastrointestinal tube becomes dislodged. This failure placed the resident at risk of complications with indwelling devices.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skill and techniques necessary to care for 1 of 10 resident's needs (Resident #44) related to PEG Tubes. The facility failed to ensure CNA C was appropriately trained on providing bed baths for residents with PEG tubes for Resident #44. This could lead to a risk of infection and medical complication, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the resident had the right to a safe, comfortable and homelike environment, for 1 of 10 residents (Resident #1) reviewed for abuse. The facility failed to ensure CNA A did not verbally threaten Resident #1 on 08/30/24. This failure placed resident at risk of abuse.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, or injuries of an unknown source were reported immediately but not later than 24 hours after the allegation was made for one (Resident #1) of four residents reviewed for abuse and neglect. The facility failed to report to the State Survey agency of an injury of unknown origin when Resident #1 was diagnosed with a L1 transverse process fracture (a break in one of the bony projections on the sides of the vertebrae). This deficient practice could place residents at risk of abuse and neglect.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for five of 20 residents (Residents #9, Resident #69, Resident #71, Resident #352, and Resident #6) reviewed for accommodation of needs. The facility failed to ensure Residents #9, #69, #71, #352 and #6's call-lights were within reach. This failure placed residents at risk of not being able to call for needed care and services which could result in not having their needs met or being unable to call for help in an emergency.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to formulate an advance directive for 3 of 5 residents (Resident #52, Resident #62, and Resident #99) reviewed for advanced directives: The facility failed to ensure Resident #52's MPOA included all pages and was signed, dated, and witnessed or notarized to confirm it was valid. The facility failed to ensure Resident #62's OOH-DNR form has the physician's license number, date of signature and printed name in the physician's statement section which made the document invalid. The facility failed to ensure Resident #99's OOH-DNR was signed and dated by a legal guardian, agent, proxy or qualified relative and witnessed or notarized or executed by two physicians which made the document invalid. [...]

Inspectors wroteBased on observation and, and interview, and record review the facility failed to maintain a clean, sanitary, comfortable, and homelike environment for two of two shower rooms (100-200 Hall and 300-400 Hall) in the facility used by the residents. The facility failed to ensure the shower curtains would close for privacy in both shower rooms used by the residents. This failure could place all residents at risk for lack of privacy, dignity, and a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents which resulted in a mechanical lift lift falling on 1 resident for 1 of 3 (Resident #6) residents reviewed for safe transfers. The facility failed to ensure the legs of the mechanical lift lift were widened during a transfer for Resident #6. This failure could place residents who require mechanical lift lift transfers at risk for falls and/or injury.

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. The facility failed to provide a system of medication records that enabled periodic accurate reconciliation and accounting for all controlled medications for 2 (300 Hall and 400 Hall) of 2 medication carts that were reviewed for pharmacy services. The facility failed to remove narcotic medications from medication carts once the order was discontinued. This failure could place the residents at risk for not receiving the therapeutic effects from controlled narcotics due to from controlled narcotics did not reconcile every shift.

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 disease and infections for 2 of 7 residents (Residents #3, #4). The facility failed to: 1. ensure MA A & CNA C donned eye protection before entering the room of residents who were on transmission-based precautions 2. ensure CNA C performed proper hand hygiene 3. ensure MA A discarded contaminated gown and gloves inside of the room of a resident who was on transmission-based precautions These failures could affect residents by placing them at risk for communicable diseases that could lead to infection, hospitalization, and death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure staff did not use physical or psychological abuse on a resident for 1 of 5 residents (Resident #1) reviewed for abuse in that: The facility failed to ensure CNA A did not raised a fist at Resident #1 stating, stop touching me and pointed her finger while stating, stop it while providing peri-care to Resident #1. This failure could place residents at risk of fear and physical/psychosocial injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents.for 1 of 5 residents (Resident #1). The facility failed to ensure each resident receives adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #1). More specifically, CNA A provided peri-care for Resident #1 without the assistance of a second staff member. This failure could place residents at risk of physical and psychosocial injury.

Inspectors wroteBased on interview, and record review the facility failed to designate a registered nurse to serve as the director of nursing on a full-time basis for the entire facility reviewed for DON coverage for 30 days 2/13/23-3/13/23. 1. DON A did not work full time hours while working as interim DON in the facility. This failure could result in a decrease in quality care for residents.