Avir at the Meadow

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide maintenance services necessary to maintain a safe, sanitary, orderly, and comfortable for 1 (Resident #1) of 5 resident rooms on the 200 Hall reviewed for safe, clean, and homelike environment. The facility failed to ensure the door handle on Resident #1's room door was working properly on 07/27/26. The facility failed to ensure the outlet cover on the wall in Resident #1's room was not bent on 07/27/26. The facility failed to ensure the hole in the wall between Resident #1's room and bathroom areas was sealed on 07/27/26. The facility failed to ensure the floor threshold between the hallway and the entryway of Resident #1's room was sealed and covered on 07/27/26. These failures place residents at risk for a diminished quality of life, infection, and clean homelike environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain a homelike environment by ensuring that 2 residents (Resident #2, and Resident #3) bedroom received the housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior for 2 (Resident #2, and Resident #3) of 8 residents reviewed for physical environment. The facility failed on 06/12/26 to remove the food on the floor from the dinner meal served on 06/11/26 in 2 residents room. This failure could place residents at risk for diminished quality of life due to unsafe, unclean, unhealthy, and unhomelike living conditionsFindings included:During an observation on 06/12/26 at 10:42 A.M., there were chicken strips and dried green peas on the floor underneath Resident #2's bed. There were also chicken strips and dried green peas on the floor between Resident #2's and Resident #3's beds. [...]

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 included measurable objectives and time frames that met the residents clinical and psychosocial needs that were identified in the comprehensive assessment for 3 (Resident #5, Resident #21 and Resident #35) out of 6 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to ensure that Resident #5's Comprehensive Care Plan included his physician's order for G-Tube, Advanced Directives, and active diagnoses.2. The facility failed to ensure that Resident #21's Comprehensive Care Plan included her active diagnoses of dementia, diabetes, schizoaffective disorder, bipolar, anxiety and she was a Smoker.3. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents (Resident #85 and Resident#9) reviewed for catheter care. The facility failed to ensure Resident #85 and Resident #9's catheters were not secured with a Stat Lock (used to secure catheters to patients inner thigh) or leg strap. This failure could place residents at risk of urethral tears or dislodging the catheter. Record review of Resident #85's quarterly MDS assessment, dated 01/30/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-entry of 01/24/2026. Her BIMs score was 12, which indicated moderate cognitive impairment. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to label drugs and biologicals used in the facility in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable, for 5 residents (Resident# 71, Resident# 13, Resident#34's, Resident# 75, Resident# 42 ) on 2 of 3 medication carts reviewed for medication storage (200 hall and 100 (secure unit) hall Medication cart) The facility failed to ensure Resident# 71's expired Nitroglycerin (a fast-acting medication used to treat or prevent angina (chest pain) by relaxing blood vessels, which increases oxygen-rich blood flow to the heart) was removed from the 100 Hall nurses' medication cart and disposed of. [...]

Inspectors wroteBased on observation, and interview, the facility failed to provide foods which were palatable, attractive, and at a safe and appetizing temperature for 1 of 1 meal observed for food preparation. (lunch 03/04/26). 1. The facility failed to serve food at an appetizing temperature for the lunch meal on 03/04/26 for the regular, mechanical soft and pureed meals. This failure could place residents who consumed food prepared in the kitchen at risk for reduced meal satisfaction, diminished nutritional intake, weight loss and a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed for kitchen safety. 1. The facility failed to ensure food in the facility's dry storage, refrigerator, and freezer areas were labeled and dated according to guidelines. 2. The facility failed to seal open items in plastic bags in the dry storage pantry, refrigerator, and freezer areas. 3. The facility failed to ensure that expired items in the dry storage pantry and freezer areas were removed. 4. The facility failed to ensure that dented cans were removed in the dry pantry area were separated from the other canned food. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 5 residents (Resident#9) reviewed for accuracy of assessments. The facility failed to ensure Resident #9's MDS accurately reflected the resident's clinical status for indwelling catheter and pressure ulcers. This failure could place residents at risk inaccurate resident assessments, inappropriate care planning, and misrepresentation of the residents' condition. Record review of Resident #9's Quarterly MDS assessment, dated 02/09/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE]. Her BIMs score was 08, which indicated his cognitive status was moderately impaired. Her diagnoses included hypertension (high blood pressure). [...]

Inspectors wroteBased on observation and interview, the facility failed to ensure the resident environment remained as free of accident hazards as possible for 1 (200 Hallway) out of 2 hallways reviewed for accidents and hazards. 1. The facility failed to ensure that the mechanical lift on the 200 Hallway was locked and secured when not in use. 2. The facility failed to ensure that the mechanical lift on the 200 Hallway in the entry of the Dining/Activity Room area was locked and secured when not in use. These failures could place residents at risk of falls and/or injury. Findings Include:Observation of the facility's 200 Hallway on 03/04/26 at 10:15 AM revealed an unlocked and unsecured mechanical lift parked in front of a resident's room. Observation of the facility's 200 Hallway on 03/04/26 at 12:11 AM revealed an unlocked and unsecured mechanical lift parked in front of a resident's room. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 1 of 5 residents (Resident#13) reviewed for respiratory care. The facility failed to ensure Resident #13's nebulizer mask was changed weekly, which was consistent with facility's policy. This failure could place residents at increased risk of infections. Record review of Resident #13's Quarterly MDS Assessment, dated 01/28/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. She had a BIMs score of 04, which indicated severe cognitive impairment. [...]

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 2 of 2 medications on 1 of 3 medication carts, reviewed for pharmacy services. The facility failed to ensure proper disposal of Resident#38's Tramadol 50 mg (controlled medication) and Resident#35's Tramadol 50 mg (controlled medication) by taping narcotic medication. This failure could place residents at risk of drug diversion and risk of pills contamination due to broken seals. Record review of Resident #38's admission MDS Assessment, dated 01/22/26, reflected the Resident #38 was a [AGE] year-old male who was admitted to the facility on [DATE]. He had a BIMs score of 08, which indicated moderate cognitive impairment. [...]

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 5 Residents (Resident#85) reviewed for infection control. The facility failed to ensure Resident #85's foley catheter was not on the floor. This failure could place residents at risk of urethral tears or dislodging catheter and urinary tract infections. Record review of Resident #85's quarterly MDS assessment, dated 01/30/26, reflected a [AGE] year-old female who was originally admitted to the facility on [DATE] and re-entry of 01/24/2026. Her BIMs score was 12, which indicated moderate cognitive impairment. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to notify residents or their representatives on how to file a grievance or complaint in an anonymous manner. The facility failed to notify residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. These failures could affect resident's ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to anonymously file their grievance.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe environment for the secure unit residents, staff and the public in two (rooms [ROOM NUMBERS]) of four resident rooms on the secure unit observed for safety. The facility failed to ensure no portable heaters or space heaters were used in residents' rooms on the secure unit. This failure could place residents at risk for injury or accidents and hazards.

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 were reported immediately, but no less than two hours after the allegation was made if the events that cause the allegation involve abuse or result in serious bodily injury, or not later than 24 hours if the events that cause the allegation did not involve abuse or did not result in bodily injury, to the facility administrator and to other officials in accordance with State law through established procedures for one (Resident #1) of four residents reviewed for abuse. The facility failed to report an allegation of abuse towards Resident #1 when reported by a staff member. This failure could place residents at risk for delayed investigation, intervention and abuse.

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's rights, that included measurable objectives and timeframes to meet a resident's medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of four residents reviewed for care plans. The facility failed to develop and implement a care plan for Resident #1 that was individualized to his care needs, which included psychotropic medications, dementia and related behaviors, and acute use of PRN antipsychotic medication after a behavioral incident. This failure could place residents at risk for inappropriate responses to behavioral symptoms and inappropriate use of psychotropic medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary drugs for one (Resident #1) of four residents who were reviewed for psychotropic medications. The facility failed to ensure Resident #1, who had a diagnosis of dementia, was administered PRN Haldol (antipsychotic) with adequate indications for its use. The facility nurse administered PRN Haldol intramuscularly when Resident #1 refused ADL care and was combative. This failure could place residents at risk for being administered unnecessary antipsychotic medication to control behaviors and could have adverse side effects including over-sedation, confusion and decreased quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were adequately equipped 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 from-four of six residents (Resident #2, #3, #4, and #5) reviewed for Resident Call System. The facility failed to ensure the call light system in Resident #2, #3, #4, and #5's rooms were in a position that was accessible to the residents on 12/30/25. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of three residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's BPAP mask and nasal canula were properly stored in a bag when not in use on 12/30/25. This failure could place the resident at risk for respiratory infection and not having his respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that assessments accurately reflected the resident's status for 2 (Resident #1 and Resident #8) of 3 residents reviewed for accuracy of assessments. The MDS did not address Resident #1 and Resident #8's oxygen use. This failure could place residents at risk of missed services, treatments, and overall decline in health. Resident #1Record review of Resident #1's face sheet, dated 11/04/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. The resident was diagnosed with other specified cough and obstructive pulmonary disease (a chronic inflammatory disease that causes obstructed airflow from the lungs). [...]

Inspectors wroteBased on observations, interviews, 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 1 (Resident #1) of 3 residents reviewed for respiratory care. Resident #1's NC was not replaced when dirty. Resident #8's 02 concentrator humidification bottle was not dated. These failures could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents with limited range of motion received appropriate treatment and services to increase range of motion and/or prevent further decrease in range of motion for two (Residents #3 and #12) of seven residents reviewed for range of motion. The facility failed to implement interventions to prevent further decline of Resident #3's and Resident #12's contracture to her left hand upon discharge from therapy services. These failures could place residents at risk for decline in range of motion, decreased mobility, and worsening of contractures.

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 2 (Med Aid cart 2 west front and Nurses cart 2 Central ) of 3 carts reviewed for pharmacy services. The facility failed to ensure: 1. LVN P, responsible for Med Aid cart 2 west front, counted controlled drugs every shift change. 2. The Nurses cart 2 Central had 1 insulin pen for Resident #24 with an expired opened date. This failure could place residents at risk of not having the medication available due to possible drug diversion. Findings Included: 1. [...]

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents obtained needed dental services, including routine dental services for 2 of 2 residents (Resident #8 and Resident #23) reviewed for dental services. The facility did not obtain routine dental services for Resident #8 and #23. This failure could place the residents at risk by contributing to mouth pain, difficulty eating and weight loss.

Inspectors wroteBased on observations, interviews, 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. 1. The facility failed to ensure food items in the facility kitchen were covered. 2. The facility failed to ensure hot holding temperature were above 135 F for three menu items on the lunch service. This failure could affect residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

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 (Resident #53) of 8 residents observed for infection control and for 2 of 2 clean linen closets observed for sanitary environment. The facility failed to ensure: 1. Clean linen closets were kept sanitary. 2. CNA N failed to performed hand hygiene and changed gloves during incontinent care for Resident #53. These failures could place residents at risk of cross-contamination resulting in infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for 2 (Resident #30 and Resident #48) of 8 residents reviewed for ADLs. The facility failed to ensure: - Resident #30 had his fingernails cleaned and trimmed. - Resident #48 had his fingernails cleaned and trimmed. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections and a decreased quality of life.

Inspectors wroteBased on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for one of two shower rooms (shower room [ROOM NUMBER]) in the facility's secured unit, reviewed for accidents and hazards. The facility failed to ensure shower room [ROOM NUMBER] was locked. These failures could place residents at risk of accidents, injury, or consuming hazardous personal care products.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 6 residents (Resident #1) reviewed for privacy. 1. Facility staff allowed a visitor to sign in as a volunteer, but was not an approved volunteer. Visitor recorded Resident #1, while at the faciity and posted the recording to social media. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure residents had the right to be free from abuse, neglect, and misappropriation of property for 1 of 6 residents (Resident #1) reviewed for abuse. 1. Resident #1 was referred to as a pig and spoken to in a rude manner on a recorded video. 2. Facility staff allowed a visitor to sign in as a volunteer, but was not an approved volunteer. Visitor recorded Resident #1, while at the faciity and posted the recording to social media. This deficient practice could cause psychosocial harm due to feelings of embarrassment and loss of dignity.

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse, neglect, exploitation, or mistreatment were reported immediately, but no later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted 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 one of one resident (Resident #1) reviewed for abuse. The facility failed to report when the Activities Assistant spoke rudely to Resident #1 and called her names on Thanksgiving Day, 11/28/24. This failure could place residents at risk of continued abuse or mistreatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a comfortable, homelike environment, with safe temperature levels within a range of 71 to 81 degrees Fahrenheit for 5 of 11 rooms (room [ROOM NUMBER], #204 #208, #210, and #213) reviewed for environmental concerns. On 01/25/24, the facility failed to ensure the temperatures in room [ROOM NUMBER], #204 #208, #210, and #213 were maintained at a safe and comfortable range, even after the facility's boiler had been adjusted. This failure could place residents at risk of an uncomfortable environment and diminish their quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that pain management was provided to residents who required such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 (Resident #36) of 8 residents reviewed for pain management. The facility failed to ensure Resident #36 received her scheduled pain medication every six hours as ordered when her supply ran out. Resident #36 received no scheduled or PRN pain medication for more than two days until surveyor inquiry causing her to experience severe pain. An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. [...]

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 (Resident #36) of 8 residents reviewed for pharmacy services. 1. The facility failed to obtain the routine scheduled pain medication for Resident #36, who was to receive it every 6 hours, for more than two days after her supply ran out. Resident #36 missed 10 doses of her scheduled pain medication causing her to experience severe pain. The medications were received after surveyor inquiry. An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free of any significant medication errors for one (Resident #36) of 8 residents reviewed for pharmacy services . The facility failed to administer the routine scheduled pain medication for Resident #36, who was to receive it every 6 hours, for more than two days after her supply ran out. Resident #36 missed 10 doses of her scheduled pain medication. An immediate Jeopardy (IJ) was identified on 11/30/23. The IJ template was provided to the facility on [DATE] at 1:12 PM. While the IJ was removed on 12/1/23, the facility remained out of compliance at a scope of pattern and a severity level of actual harm because all staff had not been trained on the corrective systems. [...]

Inspectors wroteBased on observation and interview, the facility failed to provide a private space for residents' monthly council meetings for 08 of 08 residents (Residents #14, #17, #18, #24, #25, #41, #42 and #50) reviewed for resident council. The facility did not provide a private space for resident council meetings for Residents #14, #17, #18, #24, #25, #41, #42 and #50 This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

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 5 residents (Resident #68) observed for infection control. 1. The facility failed to ensure clean linen closets were kept sanitary. 2. ADON D failed to complete hand hygiene while providing wound care to Resident #68 These failures could place residents at risk of cross-contamination resulting in infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free misappropriation of resident property for 1 of 8 residents (Resident #57) reviewed for drug diversion. The facility failed to prevent an employee with access to controlled medications from diverting an unknown number of Tylenol #3 tablets (a Schedule III narcotic drug used to treat pain) tablets belonging to Resident #57 from a medication cart. This failure could place residents at risk for unrelieved pain due to his medication not being readily available.

Inspectors wroteBased on interview and record review, the facility failed to notify the Office of the State Long-Term Care Ombudsman of the transfer or discharge and the reasons for the transfer or discharge in writing for one (Resident #228) of one resident reviewed for transfer and discharge. The facility failed to send a transfer or discharge notice in writing to the facility's Ombudsman as soon as practicable when Resident #228 was discharged on 04/10/23. 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 observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for one (Residents #15) of two residents reviewed for personal care. The facility failed to provide personal care and skin care for Resident #15 by not trimming his fingernails. This failure could place residents who require staff assistance at risk of dermatitis, infections, and low self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to implement measures to prevent further decrease in ROM for 2 of 10 residents (Residents #15 and #21) reviewed for contractures. The facility did not apply a splint on Resident #15's and Resident#21's hands to prevent a decline in ROM. This failure could place residents at risk for further decline in ROM and development of contractures.

Inspectors wroteBased on observation and interview, and record review, the facility failed to maintain an environment as free of accident hazards as is possible for two of two rooms (storage room and shower room) in the facility's secured unit, reviewed for accidents and hazards. The facility failed to ensure the storage room and shower room doors, in the secured unit were locked. These failures could place residents at risk of accidents, injury, or consuming hazardous personal care products.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care is provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 1 resident (Resident #1) reviewed for respiratory care. The facility failed to perform routine bi-pap (bilevel positive airway pressure is a machine that helps you breathe) maintenance. This failure has the potential to affect residents who use bi-pap machines in the facility.

Inspectors wroteBased on interviews and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption for 1 of 1 facility, in that: The facility did not have a policy regarding use and storage of food brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption. This failure could place residents at the facility who received food from outside sources at risk for foodborne illnesses.