Avir at Western Hills

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and help prevent the development and transmission of communicable diseases and infections for 1of 3 residents (Resident #64) reviewed for infection control. MA failed to disinfect the blood pressure cuff between use on Resident #79 and Resident #64 while performing medication administration. This failure places residents at risk for cross contamination and development of infections.

Inspectors wroteDuring Observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene; for 1 of 6 residents (Resident #1) reviewed for quality of care.-The facility failed to ensure the ADON did not leave Resident #1 without providing incontinent care, when the resident had an BM on 06/11/2026 at 2:35 pm. This failure could result in skin breakdown, infection, and a significant decline in Resident #1's health.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a 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 1 of 2 residents (Resident # 1) reviewed for resident rights. The facility failed to ensure Resident #1 was treated with dignity and respect when her foley bag was uncovered and exposed, and was 1/4 full of urine. This failure could place residents at risk of lack of comfortability and respect, as well as a decline in self-worth.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 4 of 4 confidential residents interviewed for grievances. The facility failed to notify residents in writing of the findings and actions of the grievances they filed. This failure could affect resident's right to a written decision regarding the resolution of their grievance.

Inspectors wroteBased on interview, and record review the facility failed to provide food that accommodates residents' allergies, intolerances, and preferences for 1 (Resident #1) of 5 residents reviewed for food preferences and allergies. The facility failed on 10/20/25, 10/22/25, 11/17/25, 12/8/25, and 12/27/25 to serve Resident #1 meals that excluded foods she was allergic to or foods that aligned with her religious beliefs. This failure placed residents at risk of food-related medical emergencies and did not honor their religious preferences.

Inspectors wroteBased on interview and record review, the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 residents (Resident #1) reviewed for supervision:The facility failed to put effective measures in place to prevent Resident #1 from eloping. Resident #1 was found outside the facility across the street in the parking lot of the convenience store on Saturday, 11/12/25 at 7:45 AM. The facility had a plan in place to monitor the front door, but the lock was not working to prevent Resident #1's elopement. The noncompliance was identified as PNC. The IJ began on 11-12-2025 and ended on 11-14-2025. The facility had corrected the noncompliance before the survey began.

Inspectors wroteBased on interview, and record review, the facility failed to ensure that resident received adequate supervision to prevent accidents for 1 of 1 resident (Resident #2) reviewed for elopement. On 06/11/2025 Resident #2 eloped from the facility; On 06/25/2025 a Record Review of the Facility Incident report was completed. According to the Report, it was estimated that Resident #2 left the facility between 5:30PM and 6:00PM, was found on the grounds of a nearby apartment complex, and taken to the ER with an admission time around 7:10PM. The noncompliance was identified as PNC . The Immediate Jeopardy began on 6/11/25 and ended on 6/12/25. The facility had corrected the noncompliance before the survey began. This failure placed residents at risk of physical injury.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to store, prepare, distribute, and serve food following professional standards for food service safety for 1 of 1 kitchen that was reviewed for kitchen sanitation in that: Food items were not labeled and/or dated. These failures could place all residents who received meals from the main kitchen at risk for food-borne illness.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to provide food that accommodates residents' allergies, intolerance's, and preferences for 2 of 3 residents (Resident #13 and Resident #46) reviewed for food allergies. The facility failed to honor Resident #13 and Resident #46's food preference of an alternative meal according to their meal ticket. This failure could place the residents at risk of not having their preference honored and a diminished quality of life.

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 of 3 residents (Resident #73) observed for infection prevention. The facility failed to ensure Enhanced Barrier Precautions (EBP) were implemented and used when LVN A provided gastric tube feeding for Resident #73. This failure could place residents at-risk for spread of infection.

Inspectors wroteBased on observation and interviews the facility failed to ensure the daily nurse staffing information, including the facility name, current date, total number and actual hours worked by Registered Nurses, Licensed Practical Nurses or Licensed Vocational Nurses, Certified Nurse Aides, and the resident census, was posted on a daily basis at the beginning of each shift in a prominent place readily accessible to residents and visitors for one of one facility reviewed for posted nurse staffing. The facility failed to update the daily staffing information posting. This failure could affect residents, their families, and facility visitors by placing them at risk of not having access to information regarding staffing data and facility census.

Inspectors wroteBased on Observations, interviews, and record review, the facility failed to ensure the right to be free from misappropriation of resident property for one of three residents (Resident #1) reviewed for misappropriation. The facility failed to prevent a diversion (misappropriation) of Resident #1's oxycodone HCl Oral Tablet 5 MG, 16 tablets (an oxycodone pain reliever) received through hospice and reported missing on 04/18/2025. The noncompliance was identified as PNC. The non-compliance began on 04/10/2025 and ended on 04/28/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for decreased quality of life, unrelieved pain, misappropriation of property, and dignity.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the resident environment remained as free of accident hazards as is possible for 1 (Resident #8) of 15 residents reviewed for accidents and hazards. The facility failed to ensure CNA G performed appropriate incontinent care on Resident #8 when she asked her to hold onto the bed, which subsequently led to Resident #8 losing grip of the bed, falling to the ground, and sustaining a skin tear to her right forearm and bump to the left side of her forehead. This deficient practice could place residents at risk of injuries.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident had the right to be free from misappropriation of property for 6 of 10 residents ( Resident #10, Resident #11, Resident #12, Resident #13, Resident #14, and Resident #15) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #10's Oxycodone (a schedule II controlled opioid medication used to treat moderate to severe pain) taking taken during the days of 10/17/24 through 10/21/24, and Residents #11, #12, #13, #14 and #15's hydrocodone/APAP tablets (a schedule II controlled opioid medication used to treat pain) taken on unknown dates. This failure placed residents at risk for not receiving prescribed medications for pain relief.

Inspectors wroteBased on 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 7 of 9 (Resident #10, #11, #12, #13, #14, #15, and #16) residents reviewed. A. The facility failed to ensure Resident #16 received Rifaximin (an antibiotic used to prevent hepatic encephalopathy). Ten doses of the medication were missed during the 34 days stay at the facility. B. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide each resident at least three meals daily, at regular times comparable to normal mealtimes in the community or in accordance with resident needs, preferences, requests, and plan of care for five (Resident #3, Resident #4, Resident #5, Resident #6, and Resident #7) of 15 reviewed for timely meals. The facility failed to provide lunch according to the lunch meal service schedule on 01/17/25 to Residents #3, #4, #5, #6, and #7. This deficient practice could place residents at risk of low blood sugar levels, increased stress levels, slowed metabolism rates, weakened immune systems, malnutrition, weakened hearts, and organ failures.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that each resident had the right to a safe, clean, comfortable, and homelike environment for 2 (Residents #1 and #2) of 15 residents reviewed for clean rooms. The facility failed to ensure Resident #1's and #2's rooms were clean and did not have a foul odors on 01/17/25. This deficient practice could place residents at risk of a diminished quality of life.

Inspectors wroteBased 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 one (Resident #1) of three residents reviewed for quality of care. The facility failed to complete an accurate skin assessment on Resident #1 upon readmission from the hospital on [DATE] in which six insect bites were not noted to his right hip. These failures could place residents at risk of not receiving necessary medical care, skin breakdown, and pain.

Inspectors wroteBased on interviews and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 9 of 30 days reviewed for RN coverage. The facility failed to ensure they had an RN on duty on 11/5/23, 11/11/23, 11/12/23, 11/18/23, 11/19/23, 11/25/23, 11/26/23, 12/3/23, and 12/04/23. This failure placed residents at risk of missed nursing assessments, interventions, care, and treatments.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframe's to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 1 (Resident #55) of 8 residents reviewed for care plans. The facility failed to ensure Resident #55's comprehensive care plan has non-approved abbreviations for problems which could result in the resident's actual needs not being met. This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #53) of 7 residents reviewed for unnecessary medications and the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days, except if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, for 3 (Resident #33, Resident #40, and Resident #51) of 7 residents reviewed for unnecessary medications. 1) The facility failed to ensure Aripiprazole (anti-psychotic) was prescribed for a specific diagnosis rather than for vascular dementia with behavioral disturbances for Resident #53. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents were free of a medication error rate of 5% or greater (9.68%) for 3 (Resident #10, Resident #37, and Resident #56) of 6 residents reviewed for medication administration. 1) The facility failed to ensure LVN E primed the insulin pen prior to administering insulin to Resident #37. 2) The facility failed to ensure RN B primed the insulin pen prior to administering insulin to Resident #56. 3) The facility failed to ensure MA F administered the proper dose of Fluticasone Propionate to Resident #10. These failures placed residents at risk of incorrect doses and not receiving the intended therapeutic benefit of the medications prescribed by the physician.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure drugs and biologicals were stored and labeled in accordance with currently accepted professional principles and included the appropriate accessory and cautionary instructions, and the expiration date for 1 (200 hall nurse cart) of 4 medication carts and 1 (100/200 hall) of 2 med rooms reviewed for med storage. The facility failed to ensure the 200-hall nurse medication cart was locked when unattended. The facility failed to monitor the temperature of the refrigerator in the medication room where temperature-sensitive medications were stored. The facility failed to ensure insulin pens were dated when opened. The facility failed to remove expired insulin from the med cart. These failures place residents at risk for receiving medications which were ineffective and/or not safe.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safely for one of one kitchen reviewed for food labeling and storage. 1. The facility failed to ensure the food was properly stored in the panty, refrigerator, and freezer. This deficient practice could place residents at risk of foodborne illness.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had the right to self-administer medications if the IDT determined that the practice was clinically appropriate for one (Resident #10) of six residents reviewed for medication administration. The facility failed to assess, obtain physician orders, and get IDT approval for Resident #10 to self-administer her medications. This failure could place residents at risk of not receiving the proper medication, the proper dose, or the therapeutic benefits of the medications.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 1 (Resident #57) of 16 residents reviewed for care plans. The facility failed to ensure Resident #57 comprehensive care plan had the correct medical diagnosis. This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the nurse staffing data was posted as required for 1 of 3 days (03/19/2024) reviewed for nursing services and postings. The facility failed to post the required staffing information for 03/19/2024. This failure could place residents, their families, and facility visitors at risk of not having access to information regarding staffing data and facility census.