Avir at the Lakes

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level 1 assessment accurately reflected the resident's status for 2 (Residents #2 & #48) of 6 residents reviewed for PASRR Level 1 screenings.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure services provided by the facility as outlined in the comprehensive care plan met professional standards of quality for one resident (Resident # 10) observed for hand rolls for contracture management. --facility failed to ensure handrolls were placed for Resident #10 for contracture management by following physician orders. This failure could place residents at risk of not receiving care according to physician orders. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure a resident with limited range fo motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for one (Resident #10) of 5 residents reviewed for range of motion. The facility failed to ensure handrolls were placed for Resident #10 for contracture management. This failure placed resident at risk of impaired skin integrity, further decline and decrease in quality of life and quality of care. [...]

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 for 1 of 1 medication rooms. The facility failed to ensure expired mediations were removed from all medication fridges. This failure could place residents at risk of receiving medications that are not at their intended potency and potential adverse reactions or side effects.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure medications were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 2 medication carts observed. The facility failed to ensure all insulins were labeled with a resident name and an open date. This failure could place residents at risk of receiving medications that were not ordered for them, receiving medications that are not at their intended potency, and potential adverse reactions or side effects.

Inspectors wroteBased on observations and interviews, the facility failed to ensure each bed had ceiling suspended curtains, which extend around the bed to provide total visual privacy in combination with adjacent walls and curtains for 4 rooms (Room D1, D5, D6, & D9) of 7 rooms reviewed for privacy. The facility failed to provide full privacy for residents in rooms (D1, D5, D6, & D9) These failures could place residents in these room at risk of being expose, embarrassed and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure assessments accurately reflected the resident's status for 3 of 18 residents (Resident #7, Resident #20 and Resident #22) reviewed for accurate assessments. Residents #7, #20 #22 were inaccurately coded on their MDS assessment. These failures could place residents at risk of not receiving care and services necessary for their physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of (Resident #22) 18residents reviewed for comprehensive care plan. The facility failed to review and revise Resident #22's comprehensive person-centered care plan to accurately reflect his weight loss. This failure could affect residents and place them at risk of not receiving appropriate interventions to meet their current needs. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 4 residents (CR #1) reviewed for accidents and supervision. - The facility failed to ensure CR #1 had adequate supervision to prevent an accident on 11/4/25 which resulted in a witnessed fall with injury (Acute right subdural hygroma [a collection of cerebrospinal fluid on the right side of the brain beneath the brain's dura mater [the tough, outermost layer that protects the brain and spinal cord]), which resulted in rehospitalization. - The facility failed to ensure 2 staff members remained at bedside during ADL care. This noncompliance was identified as Past Non-Compliance. The IJ began on 11/4/25 and ended on 11/5/25. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure residents who were unable to carry out activities of daily living were provided with the necessary services to maintain good personal hygiene for 2 of 6 (Resident #3 and Resident #5) residents reviewed for ADL care. The facility failed to provide Resident #3 & Resident #5 showers as scheduled. This failure could place residents who are dependent on staff for ADL care at risk for loss of dignity, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that left over food items in the walk-in cooler, were properly sealed, and labele with opened, expiration date. This failure could affect the residents who received meals from the kitchen and could place them at risk for foodborne illness.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 3 (Residents # 42, #66, and #44) of 3 residents reviewed for resident rights in that- -The facility failed to grant Residents # 42 and #66 the opportunity be with each other. -The facility failed to allow Resident #44 the right to remain in her room as she desires. These failures could place residents at risk for diminished quality of life and loss of dignity and self-worth.

Inspectors wroteBased on record review and interviews, the facility failed to electronically transmit within 14 days after the facility completed a resident's assessment, encoded MDS data including a subset of items upon a resident's transfer, reentry, discharge, and death for 8 of 16 residents (CR #79, Residents #9, #33, #44, #66, #50, #75, #382) reviewed for electronic transmission of MDS data to the CMS system. 9The facility failed to complete and transmit CR 79, Residents #9, #33, #44, #66, #50, #75, #382 MDS assessment within 14 days of the ARD date. These failures could place residents at risk of not having their assessments completed and submitted in a timely manner and having their Medicaid payments and/or services interrupted.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to assist residents in obtaining routine and 24-hour emergency dental care for 3 of 16 residents (Residents #9, #42, #66) reviewed for dental services. The facility failed to provide proper routine dental care for Residents # 9, #42 and #66. This failure could place residents at risk of oral complications, dental pain, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate assessments with the Preadmission Screening and Resident Review (PASRR) program to the maximum extent practicable for 1 of 5 residents (Resident #57) reviewed for PASRR. -The facility failed to update the PASRR Level 1 forms for Resident #57 to indicate mental health illness. This failure could place residents requiring PASRR services at risk of not having their special needs assessed and met by the facility.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the only facility kitchen. The facility failed to clean the floor in the kitchen. The facility failed to maintain clean mop water in the kitchen. The facility failed to date and label covered bowls of food on serving tray. The facility failed to clean the serving trays used to serve and store covered bowls of food. The facility failed to change the grease in the deep fryer or keep the exterior sides of the deep fryer clean. The facility failed to ensure the only sink in the kitchen for employee handwashing was free from clutter and obstacles to ease staff use. The facility failed to ensure the only alcohol-based hand sanitizer dispenser was clean and functional for staff use. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an effective pest control program for 1 of 1 kitchen, and 1 of 1 food storage area reviewed for pests. 1. Rat\mice droppings were observed in the kitchen area between the deep fryer and the stove on 06/04/24. 2. A live roach was observed in the dry food storage room on 06/04/24. This deficient practice could place residents at risk of residing in an environment with pests and at risk for food borne illness.

Inspectors wroteBased on interviews and record review, the facility failed to permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the discharge was necessary for 1 (CR #1) of 4 residents reviewed for discharge requirements. 1. The facility failed to ensure CR #1 was provided a discharge in writing. 2. The facility failed to document a discharge summary in resident clinical record. This failure placed residents at risk of not receiving necessary care and services.

Inspectors wroteBased on 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 safeguard against transmission of legionella and waterborne pathogens for 1 or 1 facility water systems. The facility failed to establish and provide documentation for a water management program as part of the infection control program. This failure could place residents at risk for Legionnaires' disease (a serious type of lung infection caused by Legionella bacteria which can live in standing water within facility water systems) and other waterborne pathogens.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan was not developed within 48 hours of a resident's admission for 1 of 7 residents (Resident #69) reviewed for baseline care plan. Resident #69 did not have a baseline care plan. This failure could have placed newly admitted residents at risk of not receiving the care and services and continuity of care.

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 7 of 18 residents reviewed for care plan accuracy (Residents #3, #10, #25, #34, #65, #62, #66). --Residents #3, #10, #25, #62's care plans did not contain level of care required for ADL assistance ---Resident #25 did not have a care plan for feeding tube or therapeutic diet --Resident #34 did not have a care plan for PT/OT --Resident #65 did not have a care plan for IV antibiotics, or midline access for IV antibiotics These failures placed residents at risk of not having their individual needs identified and addressed.

Inspectors wroteBased on record review and interview, the facility failed to conduct a comprehensive and accurate, standardized discharge assessment for 1 of 2 residents reviewed for discharge status (Resident #67). --discharge assessment was not completed for Resident # 67, discharged [DATE] This failure could place residents at risk of innacurate or incomplete information about discahrged residents and diminished qaulity of care.

Inspectors wroteBased on record review and interview, the facility failed to coordinate assessments with the (PASARR) program under Medicaid in subpart C to the maximum extent practicable to avoid duplicative testing and effort for 1 of 6 residents (Resident #34) reviewed for PASARR. The facility failed to update the PASARR Level 1 forms for Resident #34 after a new diagnosis of mental illness after admission. This failure could place residents requiring PASARR services at risk of not having their needs assessed and met by the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 1 of 6 residents (Resident # 6) reviewed for PASRR assessments. The facility failed to ensure Resident # 6 who had a diagnosis of bipolar disorder had an accurate PASARR level I assessment or received a PASARR Level II assessment or evaluation. This failure could affect residents and place all residents who admitted with a serious mental illness at risk of not receiving needed care and services to meet their individual needs.

Inspectors wroteBased on record review and interview, the facility failed to develop a comprehensive resident centered care plan for each resident consistent with resident rights for 1 of 2 discharged residents reviewed for discharge care plan (Residene #67). ---there was no care plan developed for discharge for Resident #67 This failure could place residents at risk of incorrect or incomplete information regarding discharged residents, and disruption of continuity of care

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 2 of 4 residents (Residents #27 and, #100) reviewed for pharmacy services, The facility failed to order medications timely which resulted in Resident #27 and #100 missing prescribed medications on 8/2/23. This failure could place residents at risk for worsening health concerns.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the medication error rate was not five percent (5%) or greater. The facility had a medication error rate of 11.11%, based on 3 errors out of 27 opportunities, which involved 2 of 4 residents (Residents #27 and #100), and 2 of 3 staff (RN M, and LVN O) reviewed for medication errors, in that: RN M failed to administer 2 medications (Plavix 75mg and Tramadol 50mg) to Resident #27 on 8/2/2023. LVN O failed to administer 1 medication (Pyridoxine 50mg) to Resident #100 on 8/2/23. This failure could place residents at risk for not receiving therapeutic effects of their prescribed medications and possible adverse reactions.

Inspectors wroteBased on observation, interview, and record review, the facility did not ensure residents were free from any significant medication errors for 1 of 4 (Resident #27) residents reviewed for significant medication errors, The facility failed to give Resident #27's Plavix medication, (which is an antiplatelet to prevent clots), because RN M overlooked the order. This failure could place the resident at risk of forming a blood clot which could cause a stroke, heart attack, or death.

Inspectors wroteBased on interview, and record review the facility failed to provide specialized rehabilitative services for 2 of 18 (Residents #65 and #66) residents reviewed for specialized rehabilitative services, The facility failed to ensure Residents #65 and #66 received physical therapy and as per physician orders, after being readmitted to the facility. This failure could place residents with orders for therapy at risk of not meeting their highest practicable well-being.