Avir at Veterans Memorial

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to maintain an effective pest control program so that the facility is free of pests and rodents for two rooms (102 & 305) of 1 of 1 facility reviewed for physical environment. The facility failed to maintain an effective pest control program so that rooms [ROOM NUMBERS] were free of roaches. This failure could place Residents at risk of a reduced quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure residents were free from abuse for 2 of 7 (Resident #1 and Resident #2) residents reviewed for abuse.1. The facility failed to ensure each resident was free from abuse when R#1 was hit on the hand by CNA A and2. The facility failed to ensure each resident was free from abuse when Resident #2 received rough ADL treatment by CNA AThis failure placed residents at risk of physical harm, emotional distress, and mental anguish. Findings IncludeRecord review or Resident #1's face sheet revealed an [AGE] year-old female who was initially admitted to the facility on [DATE] and readmitted [DATE] with diagnosis of Alzheimer's (irreversible brain disorder affecting memory, thinking, and behavior) disease. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to ensure that 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 24 residents (Resident #1) reviewed for quality of care.- The facility failed to transfer Resident #1 to the hospital by means of emergency services after she was observed to be in pain, had a bruise to the left lower extremity, and her extremity was observed to be out of normal alignment on 3/29/2026 at 12:00pm. Resident #1 was transferred to the hospital at 8:55pm. An Immediate Jeopardy (IJ) was identified on 4/16/26. The IJ template was provided to the facility on 4/16/26 at 10:51am. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review the facility failed to ensure that pain management was provided to residents who require such services, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for 1 of 24 residents (Resident #1) reviewed for pain.- The facility failed to monitor and address Resident #1's pain on 3/29/26 from 12:00pm to 9:00pm, when the resident was found to have a fracture to her left lower extremity and would say ouch every time she would be turned/repositioned and during incontinence care. An immediate Jeopardy (IJ) was identified on 4/16/2026. The IJ template was provided to the facility on 4/16/2026 at 10:51am. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review the facility failed to ensure each resident was treated with respect and dignity for 2 of 8 (Resident#4 and #43) residents reviewed for resident rights. The facility failed to ensure that Resident #4's television was programmed to view all channels. The facility failed on 04/14/2026 to ensure Resident #43 was treated with dignity when the facilities training mannequin was stored in the unoccupied bed of the residents room. These failures could place all residents at risk of not being treated with dignity and respect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a comprehensive person-centered care plan for each resident to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 6 residents (Resident #3, Resident #9, and Resident #12) reviewed for comprehensive care plans. 1. The facility failed to provide Resident #3 with comprehensive per-centered care plan to address Activities of Daily Living (ADL). 2. The facility failed to provide Resident #9 with comprehensive per-centered care to address her Contact isolation or Urinary Tract Infection. 3. The facility failed to provide Resident #12 with a comprehensive care plan to address her Contact isolation or Urinary Tract Infection. This failure could place residents at risk of not having personalized plans developed to address their specific care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals, and preferences for 1 (Resident #4) of 24 residents reviewed for parenteral fluids. Resident #4 had an IV in her L hand that was tender to touch, had redness, and evidence of prurial leakage. IV had not been flushed for 7 days and was not removed per physician's orders. This failure placed residents at risk for a delay in treatment, pain, and hospitalization. Findings Include: Record review of Resident #4's face sheet revealed a [AGE] year-old woman originally admitted on [DATE]. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review the facility failed to ensure the accurate acquiring, dispensing, receiving, and administering of medications for 1 of 1 medication storage rooms and 3 of 6 (Nurse 100 hall, Nurse 200 hall, and Med Aide 200 hall) medication carts, reviewed for pharmacy services. The facility failed to ensure expired medications were not stored with current medications on the 100 hall Nurse medication cart,200 hall Nurse medication cart, 200 hall Med Aide medication cart, and medication storage room. These failures could place residents at risk for not receiving the therapeutic benefit of the medication and/or worsening health concerns.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observations, interviews and record review, the facility failed to ensure residents have the right to request, refuse, and or discontinue treatment and to formulate an advance directive for 1 (Resident #80) of 24 residents whose records were reviewed for advance directives.- The facility failed to have Resident #80's code status on file from admission ([DATE]) through [DATE]. This failure could place residents at risk for not having their end of life wishes honored.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 1 (Resident #85) of 22 residents reviewed for sanitary conditions. The facility failed to clean and disinfect a mud brown smudge with a solid consistency from the wall inside of Resident #85's room for 3 days. The failure could place residents at risk of sickness and infection.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review the facility failed to refer all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment for 1 (Resident #44) of 24 residents reviewed for PASRR.The facility failed to perform a new PASRR level 1 assessment on Resident #44 due to diagnoses, of major depressive disorder (persistent, intense, low mood, or a loss of interest), generalized anxiety disorder (persistent, excessive, and uncontrollable worry), mood disorder due to known physiological condition with mixed features (mania/hypomania and depression occur together), and adjustment disorder with mixed disturbance (emotional issues and behavioral problems after a stressor). [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain grooming and personal hygiene for 1 out of 24 residents (Resident #12) reviewed for ADLs.- The facility failed to shower/bathe Resident #12 for a week (from 4/9/26-4/16/26) when she was scheduled to have one three times a week on Tue/Thu/Sat. This failure could place residents at risk of skin breakdown, infection, and reduced feelings of self-worth.

Inspectors wroteBased on record review and staff interview, the facility failed to ensure radiology services were obtained and reported in a timely manner for 1 of 8 residents (Resident #14) reviewed for radiology services.-The facility failed to ensure Resident #14 received a STAT ( immediately or without delay) chest x-ray as ordered on 04/13/2026 which delayed further medical assessment and treatment until 04/14/2026. This failure placed residents at risk of experiencing delays in clinical decision-making and treatment.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based 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 in 1 of 1 kitchen reviewed for food safety. -The facility failed to ensure food was discarded from the refrigerator prior to the use by date.-The facility failed to ensure food was labeled with a discard or use by date.-Dietary Staff A used an object to prop open the kitchen door allowing two flies to enter the kitchen. These failures could place residents at risk of foodborne illness and disease.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview, and record review, the facility failed to ensure rooms were adequately equipped to allow residents 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 2 of 8 residents (Resident #69 and Resident #109) reviewed for call systems. The facility failed to provide a functioning call light system in the rooms of Resident #69 and Resident #109. This failure could place residents at risk for a delay in care and services, increased falls, excessive wait times, pain, and a decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as was possible and ensure each resident received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure CNA A, on 10/07/25, had a 2nd staff member assisting her when transferring Resident #1 from her bed to her wheelchair and failed to ensure the mechanical lift sling was free from defects. Resident #1 fell from her bed to the floor and sustained lacerations to her head resulting in 7 stitches to her left forehead and 5 staples to her posterior scalp. The noncompliance was identified as Past Noncompliance. The Immediate Jeopardy (IJ) began on 10/07/25 and ended on 10/08/25. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents receive parenteral fluids consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for one resident (Resident #3) of 5 residents reviewed for treatments. The facility failed to follow facility protocol of cleaning and changing of the PICC line dressing for Resident #3, since his return from the hospital on [DATE] until he was readmitted to the hospital on [DATE]. This failure could lead to infections and related complications.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was treated with respect and dignity and care for each resident in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life, recognizing each resident's individuality for 4 (Resident #4, Resident #5, Resident #6, and Resident #7) of ten residents. The facility failed to ensure CNA G did not make Resident #4 feel threatened, make Resident #5 feel like a child, hurt Resident #6's feelings, and make Resident #7 feel not like a human. This deficient practice placed residents at risk of mental harm, anxiety and depression.

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 includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment and services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required for 1 of 9 residents (Resident #1) reviewed for care plans. [...]

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 one of one kitchen reviewed for dietary services. 1. The facility failed to ensure foods were sealed, labeled or dated while in storage 2. The facility failed to ensure food on the line was held at temperature of at least 140 degrees and above. These failures could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable for one of four medication carts reviewed for medication storage. -The 300-hall nurse medication cart contained opened out of date liquid and medication not stored in the original packaging. The facility failed to keep resident medications in their original containers/packaging located in the medication cart assigned to LVN M. There were 35 pills that were multicolored/different shapes, 5 1/2 white pills of various shapes and 6 pieces multicolored pills loose at the bottom of one of the drawers belonging to unknown residents. [...]

Inspectors wroteBased on interview and record review, the facility failed to maintain medical records in accordance with accepted professional standards and practices for 1 (CR #1) of 4 residents reviewed for medication administration. 1-LVN A and LVN B documented CR #1 was being monitored for behaviors and medication side effects and documented CR #1 was administered medication in the evening of 12/27/2024 and the day of 12/28/2024 while he was at the hospital. 2-LVN A documented CR #1 had a pain level of 3 (on a scale of 0-10, with 10 being the most pain) on 12/29/2024 while he was at the hospital. This failure could possibly lead to resident injury due to inaccurate documentation and reflection of resident health and care.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 2 residents reviewed for ADL care (Resident #62) who was unable to carry out activities of daily living was provided services to maintain good nutrition, for 1 of 2 residents (Resident #62) reviewed for ADL care in that: - Resident #62 missed 2 out of 4 meals observed due to staff not assisting her with feeding. This failure placed residents in need of ADL assistance at risk of malnutrition and malnourishment.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 of 1 (Resident #63) reviewed for tracheostomy care. The facility failed to enter orders for Resident #63's oxygen therapy after she returned from the hospital on [DATE]. This failure could place residents at risk for respiratory compromise and associated complications such as respiratory distress and lung damage.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to equip each room to assure full visual privacy for each resident for 3 of 10 dual rooms reviewed for privacy. The facility failed to provide curtains that surround the bed to ensure residents' privacy in Rooms A, B, and C. The rooms did not have curtain tracks on the ceiling between resident beds for privacy curtains. No other means for visual privacy between beds was provided. This failure placed residents at risk of decreased self-worth and dignity by being exposed during resident care.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain an infection control program designed to ensure a safe, sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 6 residents reviewed for infection control (Resident #83) in that: LVN E removed a packed dressing from Resident #83's left lower buttock and scratched and rubbed his back without changing her gloves. After cutting dirty dressing from Resident #83's foot LVN E placed small amount of hand sanitizer on a gauze and wiped the blades of her scissors and placed the scissors back on the clean field. These deficient practices placed resident at risk for infection and inadequate wound healing.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving injuries of unknown source, are reported immediately, but not later than 2 hours after the event, if the events result in serious bodily injury, or no later than 24 hours if the events and do not result 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 1 of 5 residents (Residents #1) reviewed for abuse and neglect, in that: The facility failed to report Resident #1's unwitnessed fall resulting in a fracture requiring hospitalization to the state agency within required time frames. [...]