Avir at Portland

Inspectors wroteBased on interviews and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but not later than two hours after the allegation is made, if the events that cause the allegation involve abuse to the administrator of the facility, for 1 (Resident #1 ) of 6 residents reviewed for abuse/neglect. The facility failed to report an allegation of verbal abuse immediately to the Administrator when CNA B witnessed CNA A using foul language at the bedside within earshot of Resident #1 on [DATE] around 1:00 am. This failure could place all residents at increased risk for potential abuse due to unreported allegations of abuse.

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 disease and infection for one (Resident #1) of five residents reviewed for infection control, in that:On 05/23/2026, CNA A did not remove her contaminated gloves nor performed hand hygiene after touching multiple surfaces prior to initiating Resident #1's perineal care. Additionally, CNA A failed to perform hand hygiene and gloves changes while performing incontinent care. These failures could place residents at risk for contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for 1 of 5 residents (Resident #1) reviewed for pharmacy services. The facility failed to ensure Resident #1's blood pressures were assessed prior to administering Metoprolol (a medication used to treat high blood pressure) per the prescribed order and blood pressure parameters in February and March of 2026. This failure could have placed residents at risk for complications and jeopardized their health and safety. The findings Included: Record review of Resident #1's face sheet, dated 03/18/2026, revealed a [AGE] year-old female with an admission date of 02/24/2026 and a discharge date of 03/11/2026 at 6:55 PM. Pertinent diagnosis included Essential Primary Hypertension (high blood pressure). [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the comprehensive care plan was developed and implemented for each resident consistent with resident rights to include measurable objectives and timeframes to meet residents medical, nursing, mental, and psychosocial needs identified in the comprehensive assessment for 2 of 5 residents (Resident #1 and Resident #2) reviewed for care plans. The facility failed to develop the comprehensive care plans for Resident #1 and Resident #2. These failures could place residents at risk of receiving improper or inadequate care and services.

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 (Resident #2) of 5 residents reviewed for infection control practices. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from significant medication errors for two (Resident #16 and Resident #34) of six residents reviewed for medication errors in that: 1)Resident #16's blood pressure was not taken to assess if Resident #16 required her blood pressure/pulse altering medications (Midodrine HCl Oral Tablet) for 29 days in the month of August 2025 and 0 days in September 2025 per physician orders. 2) Resident #34's blood pressure was not taken to assess if Resident #34 required her blood pressure/pulse altering medications (Lisinopril 10 mg Oral Tablet) for 6 days in the month of September 2025 and 18 days in the month of August 2025 per physician orders. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety in one of one kitchen reviewed for dietary services. 1. The facility failed to ensure the ice machine was clean. 2. The facility failed to ensure food/ drink items in the reach-in refrigerators and freezers, dry storage area, and kitchen area were properly stored, labeled, and dated. 3. The facility failed to ensure cleaned dishes did not have food or beverage residue in or on them. 4. The facility failed to ensure the floor, dish washing machine, and dirty and clean dish washing tables did not have food residue and other trash on them. 5. The facility failed to ensure the dish machine temperature and sanitizing log was filled out 3 times a day. [...]

Inspectors wroteBased on observation and interview the facility failed to ensure the resident's right to privacy for 1 (Resident #11) of 6 residents reviewed for dignity in that:The WCN did not provide privacy for Resident #11 while performing his wound care. This failure could cause residents to feel uncomfortable, disrespected, and possibly a loss of dignity due to a lack of privacy.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #49) of three residents reviewed for urinary catheters. The facility failed to ensure LVN C changed Resident #49's urinary catheter drainage bag on 09/01/25 per the physician's order. This failure places residents with urinary catheters at risk for urinary tract infections. Record review of Resident #49's admission record reflected a [AGE] year-old male originally admitted to the facility on [DATE] with most recent admission on [DATE]. [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure all drugs and biologicals were stored in locked compartments and labeled in accordance with currently accepted professional principles reviewed for medications stored in 1 of 4 medication carts (Nursing cart 1) reviewed for storage. The facility failed to keep nursing cart 1 locked when not in use. The failure could place residents in the facility at risk of drug diversion or misuse of medications leading to harm.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to maintain medical records on each resident that were accurately documented for one (Resident #49) of four residents reviewed for medical records. The facility failed to ensure LVN C did not document care that was not provided on 09/01/25. This failure could affect residents whose records were maintained by the facility and could place them at risk for errors in care and treatment. Record review of Resident #49's admission record reflected a [AGE] year-old male originally admitted to the facility on [DATE] with most recent admission on [DATE]. [...]

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 1 (Resident #11) of 6 residents reviewed for infection control practices.1) The WCN did not perform hand hygiene after removing gloves before, during, and after performing Resident #11's wound care. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections.

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 2 of 3 (Resident #1 and Resident #2) residents reviewed for respiratory care. The facility failed to obtain/verify physician's orders to administer oxygen at 3 LPM for Resident #1 from 06/02/25 to 06/23/25 and oxygen at 2 LPM for Resident #2 from 06/19/25 to 07/01/25. This deficient practice could place residents who receive respiratory care at an increased risk of developing respiratory complications and a decreased quality of 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 for the facility's only kitchen and two of two resident nutrition rooms reviewed for dietary services in that: 1. The facility failed to ensure that both of the reach- in refrigerators and both of the reach- in freezers had separate thermometers inside and/ or at the front near the door per facility policy. 2. The facility failed to ensure that the dry storage room had a thermometer in it per facility policy. 3. The facility failed to ensure that refrigerator and freezer temperatures were recorded three times per day per facility policy. 4. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain an effective pest control program so that the facility was free of pests in one of one kitchen reviewed for pests. 1. There were multiple live roaches in the kitchen. This failure could put residents at risk for food contamination and/or food borne illnesses.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' right to privacy for 2 (Resident #33 and Resident #70) of 19 residents reviewed for privacy. 1) The facility failed to ensure a printed sheet of paper containing Resident #70's laboratory values was secured and out of view from the public at 4:17 PM on 08/15/2024. 2) The facility failed to ensure RN A locked the computer screen that displayed Resident #33's personal medical information while RN A was away from the computer administering medication to Resident #33 at 8:13 AM on 8/16/2024. These failures could allow residents' protected HIPAA information to be shared with individuals who do not have a need or right to know which could place residents at a risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on interviews and record reviews, the facility failed to send a copy of the notice of transfer or discharge, and the reasons for the transfer or discharge in writing to the resident, resident representative, or the Office of the State Long-Term Care Ombudsman for one (Resident #11) of three residents reviewed for transfer and discharge. The facility failed to send the notice of transfer or discharge in writing to Resident #11, Resident #11's representative or the Ombudsman when Resident #11 was discharged to the hospital on 6/27/2024. This failure could affect residents at the facility by placing them at risk of being discharged and not having access to available advocacy services, discharge/transfer options, and the appeal processes.

Inspectors wroteBased on record review and interviews, the facility failed to ensure a PASRR evaluation was completed on newly admitted residents prior to admission or after admission for 2 (Resident #34 and #3) of 8 residents reviewed for PASRR screenings. 1. The facility failed to ensure Resident (R) #34's PASRR Level 1 screening indicated R #34 was positive for mental illness. 2. The facility failed to ensure Resident (R) #3's PASRR Level 1 screening indicated R #3 was positive for mental illness. These failures placed 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 consistent with the resident rights that include measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychological needs that were identified in the comprehensive assessment for revisions for care plans for 1 (Resident #41) of 4 residents reviewed for care plans. The facility failed to ensure Resident #41's (R#41) most recent care plan was updated for a fall with injury on 08/11/24, updated fall precautions, bed in low position, call light in place/within reach, scoop mattress, and fall matt on floor beside bed. This deficient practice could place residents at risk of not being provided with the necessary care or services and not having personalized plans developed to address their specific needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 (Resident #4 and #70) of 3 residents reviewed for indwelling urinary catheters. 1. Resident #4's catheter tubing was dragging on the ground underneath his wheelchair in the lobby area outside resident halls 500 and 600 at 10:58 AM on 08/14/2024. Resident #4's catheter bag and tubing were dragging on the ground underneath his wheelchair in the dining room during lunch at 12:39 PM on 08/14/2024. 2. Resident #70's catheter bag was on resting on the floor as he laid in bed at 3:00 PM on 08/14/2024. These deficient practices could place residents with indwelling urinary catheters at-risk for urinary tract infections and/or pain.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services to include procedures that assured the accurate dispensing and administering of all drugs to meet the needs of 1 of 6 residents (Resident #59) reviewed for medication administration in that: The facility failed to ensure Resident #59's medication was fully administered after a nebulizer (electric device that turn liquid medicine into a mist) treatment was initiated, leaving Resident #59 left over medication in the nebulizer container allowing Resident #59 access to the medication at a later time. This deficient practice could affect residents and place them at risk of not receiving therapeutic dosage and drug diversion.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of significant medication errors for 1 of 1 residents (Resident # 1) reviewed for significant medication errors, in that; The facility administered Resident #1's Clonidine outside of physician ordered parameters which resulted in Resident #1 being transferred to the hospital due to low blood pressure. This failure placed residents at risk for not receiving therapeutic dosages and placed them at risk for a decline in health. The noncompliance was identified as Past Non-Compliance. The facility had corrected the noncompliance before the investigation began.

Inspectors wroteBased on interviews and record reviews the facility failed to immediately inform the physician and/or resident/responsible party when there was a need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment) for one (Resident #1) of five residents reviewed for physician notification of changes. 1. The facility failed to notify the physician of Resident #1's wounds when she was admitted to the facility on [DATE]. 2. The facility did not consult with Resident #1's physician to reconcile Resident #1's hospital discharge wound treatment orders for specific wound care instructions upon admission on [DATE]. 3. The facility failed to notify the physician upon the discovery of Resident #1's worsening wound on 12/24/23. An immediate jeopardy was identified on 04/09/24. [...]

Inspectors wroteBased on record review and interview, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for one (Resident #1) of five residents reviewed for quality of care. 1. Upon admission on [DATE] at 03:43 PM, the facility failed to perform a thorough, comprehensive head to toe assessment and correctly identify, describe, and document the multiple wounds of Resident #1. 2. Provide Resident #1 with wound care to her wounds as indicated in her hospital discharge orders on 12/16/23. Resident #1 did not receive wound care orders until 11 days later on 12/27/23. 3. The facility did not consult with Resident #1's physician to reconcile Resident #1's hospital discharge wound treatment orders for specific wound care instructions upon admission on [DATE]. 4. [...]

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 a resident's medical, nursing, mental, and psychosocial needs for one (Resident #1) of five residents reviewed for care plans. 1. The facility failed to address and include objectives, goals, and interventions specific to Resident #1's surgical and other wounds, oxygen therapy, fall risk, or pain that were present upon her admission on [DATE]. 2. The facility failed to immediately update Resident #1's care plan upon a change in condition, specifically when Resident #1's wounds were found to be worse on 12/24/23. This failure could place residents at increased risk of not having their individual needs met and decreased quality of life.

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 a resident's medical, nursing, mental, and psychosocial needs for one (Resident #1) of five residents reviewed for care plans. 1. The facility failed to address and include objectives, goals, and interventions specific to Resident #1's surgical and other wounds, oxygen therapy, fall risk, or pain that were present upon her admission on [DATE]. 2. The facility failed to immediately update Resident #1's care plan upon a change in condition, specifically when Resident #1's wounds were found to be worse on 12/24/23. This failure could place residents at increased risk of not having their individual needs met and decreased quality of life.

Inspectors wroteBased on observations and interview , the facility failed to provide privacy for 1 (Resident #1) of 8 residents observed for incontinent care in that: Resident #1's room door was left open, and the curtain was not drawn during incontinent care offering no privacy, allowing full visual exposure of Resident #1 on 11/14/2023 at 5:08am. This deficient practice could affect residents who require care and monitoring and place them at risk of not receiving privacy and dignity during personal care and services to meet their needs.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to notify local authorities of a suspicious injury for 1 of 1 resident reviewed for injuries of unknown origin in that: Resident #1 had an injury of unknown origin The facility failed to implement their policy by not reporting suspicions of abuse for a resident with injuries of unknown source. This failure could place residents at risk for potential criminal activity without consequences

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food by professional standards for food service safety for 1 of 1 kitchen reviewed for sanitation *There was an undated and unlabeled personal item in the kitchen refrigerator *A pie was found unlabeled and undated in the kitchen refrigerator *A cook did not know how to calibrate a thermometer *The steam table wells had scaling and rust in them *The daily cleaning log was missing data These failures could place residents at serious risk for complications from food contamination.

Inspectors wroteBased on observation, interview, and record review, the facility failed to allow a resident to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for one resident (resident #128) of twenty-five residents reviewed for environment. The facility failed to ensure Resident #128 had a working call light. This failure could place residents at risk of not being able to get staff assistance when they require it.