Avir at Pasadena

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 reviewed for food procurement in that: -Food items expired, and Food items not labeled or dated. These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness and disease.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide a safe, clean and comfortable homelike environment for 1 of 8 residents (Resident #11) reviewed for a homelike environment. The facility failed to ensure that Resident #11's room was a clean and comfortable homelike environment. The failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible, and each resident received adequate supervision to prevent accidents for 1 of 18 residents (Resident #91) reviewed for accidents and supervision, in that: The facility failed to supervise Resident #91 on the secure unit, after he attempted to elope 20 minutes prior to eloping, out of the window on 12/31/23. An Immediate Jeopardy (IJ) was identified as past non-compliance on 11/21/24. The non-compliance began on 12/31/23 and ended on 1/2/24. The facility had corrected the non-compliance before the survey began on 11/19/24. This deficient practice could place residents who were elopement risks at-risk of harm, serious injury, or death.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. The facility did not ensure the dishwasher was above the appropriate sanitizing temperature of 120 degrees Fahrenheit. This failure could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 6 residents (Residents #81) reviewed for activities, in that: The facility failed to ensure Resident #81 participated in one-on-one in-room activities since January 2024. This deficient practice could place residents at risk of decline in psychosocial well-being and their physical health.

Inspectors wroteBased on observations, interviews, and record reviews, 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 (Resident #67 and Resident #88) of 5 residents reviewed for infection control. 1. CNA F did not wear appropriate PPE when helping Resident #67, a resident on Enhanced Barrier Precautions, transfer from wheelchair to bed. 2. LVN G did not wear appropriate PPE when she was giving Resident #88, a resident on Enhanced Barrier Precautions, medications through his G-tube (tube into stomach for nutrition). These failures could place residents at risk for cross-contamination, and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety in 2 of 2 facility refrigerators and 1 of 1 dry food storage areas reviewed for food procurement in that: - The facility failed to label and date food items in the kitchen walk-in refrigerator and resident refrigerator located in the medical records room. - The facility failed to label and date all food items located in the dry food storage area. These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness.

Inspectors wroteBased on interview and record review the facility failed to implement written policies and procedures that prohibit and prevent residents from abuse, neglect, exploitation, and misappropriation of resident property for 3 (the Administrator, Dietary A, and Housekeeping #A) out of 19 employees reviewed for annual EMR/NAR checks. The facility failed to ensure EMR/NAR checks were completed annually for the Administrator, Dietary A, and Housekeeping #A. The facility failed to keep a copy of the results of the initial and annual searches of the NAR and EMR in the employee's personnel file. This failure could place residents at risk of abuse, neglect, and/or misappropriation of personal property.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable for 1 of 6 residents reviewed for PASARR. -Resident #39 had a diagnosis of mental illness and the facility did not coordinate with the appropriate, State-designated authority. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health.

Inspectors wroteBased on interview and record review the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for 1 of 1 (CR #2) residents reviewed for notification of changes in that: The facility failed to notify the physician when CR #2 displayed a change in condition on 1/22/23. An Immediate Jeopardy (IJ) was identified on 8/30/23 at 2:44pm. While the IJ was removed on 8/31/23 at 3:56pm the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. This failure could place residents at risk for a decline in health, and possible death.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices, for 1 of 1 resident (CR #2) reviewed for quality of care. -The facility failed to provide needed care and services resulting in a decline of CR #2's physical, mental, and psychosocial wellbeing on 1/22/23. -CR #2 was identified as unresponsive at 11:00am on 1/22/23 by the family, and only at the request of the family was CR #2 sent out to the hospital. An Immediate Jeopardy (IJ) was identified on 8/30/23 at 2:44pm. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure licensed nurses had the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 1 of 1 nurse (LVN A) reviewed for nursing services. LVN A failed to identify CR #2 was unresponsive on 1/22/23. LVN A got CR #2 into her wheelchair and attempted to give her water to drink, when she was unresponsive. An Immediate Jeopardy (IJ) was identified on 8/30/23 at 2:44pm. While the IJ was removed on 8/31/23 at 3:56pm the facility remained out of compliance at a severity level of actual harm and a scope of isolated due to the facility continuing to monitor the implementation and effectiveness of their corrective systems. [...]

Inspectors wroteBased on observation, record review and interview, the facility failed to follow written policies on permitting residents to return to the facility after they were hospitalized or placed on therapeutic leave for 1 of 2 closed Records (CR #1) reviewed. 1. The facility failed to readmit CR #1 after he was hospitalized . This failure could place residents, who transfer to the hospital, at risk of being denied readmission to the facility.