Avir at Town Creek

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse for 2 of 7 residents (Residents #1 and #2) reviewed for abuse. The facility failed to report abuse on 2/4/26 at approximately 3:38 p.m. when Resident #2 allegedly struck Resident #1 in the face with a closed fist. This failure could place residents at risk of abuse, emotional distress, and loss of dignity.

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 food safety requirements and kitchen sanitation. The facility failed to ensure all food items stored in the refrigerator and freezer were dated and labeled. These failures could place residents at risk of foodborne illness and food contamination.

Inspectors wroteBased on observations, interviews, and record reviews 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 2 of 4 residents (Resident's #2 and #3) and 2 of 5 staff (CNA B and LVN G) reviewed for infection control. 1. The facility failed to ensure CNA B changed gloves and washed or sanitized her hands when providing care to Resident #2 on 8/12/2025.2. The facility failed to ensure LVN G changed gloves and washed or sanitized her hands during wound care to Resident #3 on 08/12/2025. These failures could place residents at risk of exposure to infectious diseases due to improper infection control practices.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 1 of 12 (Resident #6) residents observed for care. The ADON failed to provide Resident #6 with full privacy while providing gastric tube care on 08/12/25. This failure could place residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable and homelike environment 1 of 4 halls (room [ROOM NUMBER]) reviewed for environment. The facility failed to repair the window in Resident #2's room [ROOM NUMBER] that had a broken frame that had detached from the wall on 8/12/2025. This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications for 1 of 1 resident reviewed for tube feeding management (Resident #6). The facility failed to follow their policy for maintaining Resident #6's positioning while administering medications via gastrostomy tube on 8/12/2025. The facility failed to follow their policy for labeling gastrostomy tube feeding for Resident #6 on 08/12/2025. These failures placed the resident at risk for aspiration of water/feedings and reduced therapeutic effects of gastrostomy feedings by not following current clinical standards of care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 2 smoking areas (secured unit smoking area) reviewed for smoking safety. The facility failed to ensure paper and plastic trash were not discarded into the fire safety can on 8/12/2025. This failure could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming, and personal and oral hygiene were provided for 3 of 12 residents (Residents #18, #3, and #22) reviewed for ADL care. 1. The facility failed to ensure Resident #18 had clean and trimmed nails on 3/24/25 and 3/25/25. 2. The facility failed to ensure Resident #3 had clean and trimmed nails on 3/34/2025 and 3/25/2025. 3. The facility failed to shave Resident #22 and she had facial hair on her chin and lip on 3/24/2025. These failures could place residents at risk of not receiving care/services, decreased quality of life, and loss of dignity.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items, per facility policy, for 1 of 8 resident's (Resident #5) personal refrigerators reviewed for food and nutrition services. The facility failed to ensure a personal refrigerator on 3/24/2025 and 3/25/2025 for Resident #5 did not have a plastic bag of sliced cheese dated 9/24/2024. These failures could place residents at risk for food borne illnesses.

Inspectors wroteBased on observation, 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 resident's choices for 1 of 4 residents reviewed for quality of care in that: The facility did not prevent the development and worsening of two facility acquired wounds for Resident #1. The facility failed to ensure a bed of appropriate size to prevent the developement and worsening of wounds was provided for Resident #1. The facility failed to document weekly skin assessments for Resident #1. The noncompliance was identified as PNC. The past noncompliance began on 12/02/24 and ended on 01/27/25. The facility had corrected the noncompliance before the survey began. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents were provided with a separate bed of proper size and height for the safety and convenience of the resident for 1 of 4 residents (Resident #1) reviewed for appropriate functional furniture. The facility failed to ensure Resident #1 had a bed of proper size for his safety to prevent development and worsening of two facility acquired wounds. The noncompliance was identified as PNC. The past noncompliance began on 12/02/24 and ended on 01/27/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for discomfort, skin breakdown and a decreased quality of life.

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 4 of 92 days reviewed. (April 2024, May 2024, and June 2024). The facility did not have RN coverage for 4 days in June 2024. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.

Inspectors wroteBased on observations, interviews, 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 baking sheets did not have brown and/or black baked on build up on 9/30/2024. The facility did not ensure the chemical sanitizer for the dish machine was at the appropriate sanitization according to the manufacturer's guidelines for the machine from 9/1/2024-9/30/2024. The facility did not ensure scoops were not left in a bin that contained flour on 9/30/2024. These failures could place residents who eat from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on interviews and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS reviewed for administration (Fiscal year 2024 for the third quarter April 1, 2024 to June 31, 2024) The facility failed to submit accurate RN hours for: 04/06 (SA); 04/07 (SU); 04/11 (TH); 04/12 (FR); 04/14 (SU); 04/20 (SA); 04/21 (SU); 04/27 (SA); 05/05 (SU); 06/08 (SA); 06/09 (SU); 06/15 (SA); 06/16 (SU); 06/17 (MO); 06/18 (TU); 06/19 (WE); 06/20 (TH); 06/21 (FR); 06/24 (MO); 06/25 (TU); 06/26 (WE); 06/27 (TH); 06/28 (FR); 06/29 (SA); 06/30 (SU) These failures could place residents at risk for personal needs not being identified and met.

Inspectors wroteBased on interviews and record review, the facility failed to inform residents in advance of the risks and benefits of proposed care and treatment for 1 of 9 residents (Resident #31) reviewed for psychotropic medications (medications that affect behavior, mood, thoughts, and perception). The facility failed to obtain a signed consent for psychotropic medications for Resident #31 that included: mirtazapine, risperidone, trazodone, Depakote, clonazepam, and Zyprexa that were administered to her. The failure could affect residents who received psychoactive medications without informed consents and place residents at risk of receiving unnecessary psychotropic medications.

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, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Resident #14 and #25) reviewed for infection control. The facility failed to ensure CNA B properly performed hand hygiene during incontinent care to Resident #14 on 9/30/2024. The facility failed to ensure LVN A properly cleaned reusable equipment when providing care to Resident #25 on 9/30/24. These failures could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observations, interviews, and record reviews 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 4 staff (CNA C) and 1 of 4 residents (Resident #1) reviewed for infection control. CNA C did not wash or sanitize her hands when changing gloves while performing incontinent care to Resident #1. These failures could place residents at risk of exposure to communicable diseases and infections. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be free from abuse for 2 of 10 residents reviewed for abuse (Resident # 4 and Resident #5) in that: On 10/15/2023, the facility did not protect Resident #4 from verbal abuse when LVN B told Resident #4 to stop acting like a damn fool with RN C present. LVN B was allowed to finish her shift, she continued to work with Resident #4 and did not leave the facility until 6:51 pm that day. On 8/20/2023, the facility failed to protect Resident #5 from physical abuse perpetuated by Resident #2 who was supposed to be on 1:1 monitoring. These failures could put residents at risk of psychosocial harm including mental anguish, depression, and becoming withdrawn.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement written policies and procedures to prohibit and prevent abuse for 2 of 10 residents (Resident #4 and Resident #5) reviewed for abuse policies. On 10/15/2023, the facility did not protect Resident #4 from verbal abuse when LVN B told Resident #4 to stop acting like a damn fool with RN C present. LVN B was allowed to work on 10/15/2023 until her shift ended. The facility did not report the incident to the abuse coordinator until 10/19/2023. On 8/20/2023, the facility failed to protect Resident #5 from abuse when he was choked by Resident #2 who was on 1:1 monitoring on 8/20/2023. These failures could place residents at risk of abuse which could lead to further abuse and neglect of other residents.

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 and misappropriation of resident property, were reported immediately, but not 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 (which included to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 10 residents (Resident #4) reviewed for abuse. The facility failed to report an incident of abuse on 10/15/2023 when LVN B told Resident #4 to stop acting like a damn fool with RN C present. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the residents received adequate supervision for 1 of 6 residents (Residents #2) reviewed for accidents, hazards, and supervision in that: On 8/20/2023, the facility failed to provide adequate supervision in the secured unit with Resident #2 who was physically aggressive towards Resident #5. On 8/20/2023, the facility failed to protect Resident #5 from physical abuse perpetuated by Resident #2 who was supposed to be on 1:1 monitoring when Resident #2 choked his roommate Resident #5. This failure could place residents at risk of psychosocial harm including mental anguish, depression and becoming withdrawn.