Avir at Itasca

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation and interview, the facility failed to provide a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and support for daily living safely for 1 of 1 facility observed.A)The facility failed to ensure the walls in the secure unit were free of gouges, scuffs, holes, peeling paint, and shredded sheetrock.The facility failed to ensure the handrails in the secure unit were free from peeling paint.The facility failed to ensure the blinds in the secure unit dining room were not broken.The facility failed to ensure the community shower room toilet was clean from feces and urine.The facility failed to ensure the floor tile was not broken and missing in the hallway in front of the kitchen entrance.B)The facility failed to empty Resident #20's 3 bedside urinals observed full on 01/06/26 and 01/07/26 at different times of the day resulting in a urine odor, gnats/flies, and unsanitary environment.This failure could place residents at risk of feeling…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 kitchen sanitation. The facility failed to ensure stored food in 1 of 2 reach in refrigerators were labeled and dated. The facility failed to ensure expired items were removed from dry storage and discarded. The facility failed to ensure Dietary Aide A properly sanitized a food thermometer when taking food temperatures for lunch services on 01/07/26. These failures could place residents who received prepared meals from the kitchen at risk for foodborne illness and cross-contamination.The findings included: During an initial tour on 01/06/26 beginning at 10:00 AM of the one and only kitchen revealed: 1 of the 2 reach-in refrigerators in the dry storage room of the kitchen contained a large zip sealed bag holding smaller prepackaged bags of sliced sandwich meat. Neither the large zip seal bag or the smaller bags inside contained the open date or the use by date.The dry…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the residents' right to be treated with respect and dignity during personal care for 1 of 6 residents (Resident #39) reviewed for respect and dignity in that:The facility failed to ensure RN A provided resident care with the door shut during an observation on 1/7/2026 at 9:13 am of wound care.The failure could place residents at risk for a lack of privacy. Findings included:Review of Resident #39's undated face sheet reflected Resident #39 was a [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of paraplegia (paralysis affecting the lower half of the body), non-pressure ulcer of the right foot, non-pressure ulcer of the left foot, and unspecified open wound to the left ankle.Record review of Resident #39's quarterly MDS assessment, datd 10/10/2025, reflected Resident #39 had a BIMS score of 7 indicating she was cognitively impaired. Resident #39 required partial to moderate assistance with bathing and was…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 #39) of 6 residents reviewed for infection control practices.The facility failed to ensure RN A used a clean technique on Resident #39's right and left foot ulcers during an observation of wound care on 1/7/2026 at 9:13 am.The failure could place residents at risk for healthcare associated cross contamination leading to worsening pressure ulcers, discomfort, pain, and potential infections.Findings included:Review of Resident #39's undated face sheet reflected Resident #39 was a [AGE] year-old female admitted to the facility on [DATE] with diagnoses of paraplegia (paralysis affecting the lower half of the body), non-pressure ulcer of the right foot, non-pressure ulcer of the left foot, and unspecified…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to ensure an effective pest control program was implemented so the facility was free of pests and rodents for 1 of 1 facility reviewed for pest control. The facility failed to keep an effective pest control program to ensure areas including residents' rooms and kitchen (dry storage) were free of flies and gnats. This failure could place residents at risk for reduced quality of life and poor sanitary environment.An observation on 01/06/26 at 10:00 AM, in the kitchen revealed a swarm of gnats surrounding a box of spoiled bananas and 50-pound bag of spoiled onions in the dry storage room. An observation on 01/06/26 at 11:41 AM, in Resident #20's room observed gnats in the room and near 3 full bedside urinals. Urine odor noted in the room. An observation on 01/07/26 at 11:14 AM, in Resident #20's room observed gnats in the room appeared around Resident #20 and appeared to be attracted to 3 full bedside urinals that appeared to have not been emptied. A fly was also noted at this time flying around the room. Urine…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, clean, comfortable, and homelike environment for 7 of 12 residents reviewed for environment. 1. The facility failed to ensure the secure unit was a comfortable temperature on 11/26/24, and Residents #1, 2, 3, 4, 5, and 6 felt uncomfortably cold. 2. The facility failed to ensure Resident #7's room was free of holes, paint scuffs, and had a well-fitting screen for the window. These failures placed residents at risk of discomfort and diminished quality of life. Findings included: Review of the undated face sheet for Resident #1 reflected an [AGE] year-old female admitted to the facility on [DATE]. Diagnoses included hypertension, anemia, underweight, osteoarthritis of hip, pain in right lower leg, and dementia. Review of the quarterly MDS assessment for Resident #1 dated 08/23/24 reflected a BIMS score of 03, indicating severe cognitive impairment. It also reflected she required supervision/touching…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review the facility failed to maintain the resident's privacy during wound treatments for 2 of 2 resident (Residents #8 and #13) reviewed for privacy. The facility failed to ensure Dr-B and the ADON protected the resident's privacy by closing the curtain and/or the resident's door when performing wound care on Resident #8 and Resident #13. This failure could place residents at risk for embarrassment, shame, and loss of dignity. Findings include: Record review of Resident #8's undated face sheet, revealed she was an [AGE] year-old female admitted [DATE] with diagnoses of Pressure ulcer Stage 3 (skin damage extending into muscle) depression, Hyponatremia (low sodium), Dementia, and Fracture of the lower leg. Record review of Resident #8's Quarterly MDS assessment dated [DATE] revealed a BIMS score of 9, which indicated the resident's cognitive ability was moderately impaired. Record review of Resident #8's Care Plan dated 8/6/24 reflected a Focus area was initiated for…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record review the facility failed to ensure assessments accurately reflected the resident's status for 1 of 4 residents (Residents #36) reviewed for resident assessments. The facility failed to ensure Resident #36's Quarterly MDS reflected that Resident #36 primary diagnosis of orthostatic hypotension. This deficient practice could place residents at-risk for inadequate care due to inaccurate assessments. Findings include: A record review of Resident #36's face sheet dated 10/09/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36's diagnoses included orthostatic hypotension (a type of low blood pressure that occurs when you stand up after sitting or lying down), age related nuclear cataract bilateral (a common cause of blindness in older adults and the elderly), and ocular pain left eye (sharp and throbbing pain in the eye), muscle weakness (loss of muscle strength of the inability to move a muscle normally), and vascular dementia (occurs when…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews 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 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 of 4 residents (Residents #36) reviewed for comprehensive care plans. Resident #36's comprehensive care plan did not reflect Resident #36's primary diagnosis of orthostatic hypotension. This deficient practice could place residents at risk for not receiving proper care and services due to inaccurate care plans. Findings include: A record review of Resident #36's face sheet dated 10/09/24 reflected an [AGE] year-old female who was admitted to the facility on [DATE]. Resident #36's diagnoses included orthostatic hypotension (a type of low blood pressure that occurs when you stand up after sitting or lying down), age related nuclear cataract bilateral (a…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 1 of 12 residents' (Resident #34) refrigerators reviewed. Resident #34's personal in-room refrigerator was not monitored for safe temperatures. This deficient practice could place residents who had personal in-room refrigerators at risk of food borne illnesses. The findings were: A record review of Resident #34's face sheet dated 10/10/24 reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Resident #34's diagnoses included essential hypertension (a type of blood pressure that develops gradually over time and has to clear cause), major depression disorder (a mental health condition that involves a persistent feeling of sadness, loss of interest, or low mood that last for a long time), Gastro-esophageal reflux disease with esophagitis without bleeding (occurs when stomach contents leak back into the esophagus, causing inflammation and…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to notify the Resident representative when the Resident experienced a significant change in condition for 1 (Resident #1) of 7 Residents reviewed for Resident rights. The facility failed to notify Resident #1's Family Member or Hospice Agency of his x-ray results that showed he had a left hip fracture on 05/15/24 due to Resident #1 falling on 05/14/24. The facility failed to notify Resident #1's Family Member or Hospice Agency that he was transferred to the hospital on [DATE] due to the left hip fracture which was revealed from an x-ray taken on 05/15/24 due to Resident #1 falling on 05/14/24. This failure could result in the Resident representative not being aware of conditions that may require them to make medical decisions. Findings included: Record review of Resident #'1s face sheet dated 07/18/24 reflected an [AGE] year-old male admitted to the facility on [DATE]. Resident #1's diagnoses included: dementia (a syndrome associated with many…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to store and prepare food in accordance with professional standards for food service safety in the facility's only kitchen reviewed for food and kitchen safety. The facility failed to label and date food products io the refrigerator and thaw foods appropriately. There failures could place residents at risk for food-born illness. Findings included: Observations on 8-22-2023 at 8:30 AM of the facility's refrigerator revealed parmesan cheese and sliced American cheese loosely wrapped, exposed to the air, without labels to signify the date in which the product was opened and when it was supposed to expire. Observations on 8-22-2023 at 8:30 AM of the facility's freezer revealed two large containers of ice cream that were not labeled or dated. The outside of the ice cream tubs were covered in a 1/2 inch layer of frost. Interview on 8-22-2023 at 8:35 AM with the KM revealed she knew that food was supposed to be labeled and dated but was unsure how long the facility policy allowed food to be stored in the refrigerator.…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on observation, interview, and record review, the facility failed to maintain an effective ongoing pest control program to ensure the facility was free of pests and rodents for 4 of 8 resident rooms (rooms 1, 3, 5, and 7) reviewed for issues with pest control. The facility failed to follow their pest control company's recommendations to prevent pests' and rodents' entry into the building. This failure could place residents at risk for exposure to diseases carried by rodents. Findings included: Interview on 8-22-2023 at 10:03 AM with the RN on the SU revealed that the SU had recent rodent activity on the SU about 1 month ago. She explained that there was a rodent problem, which stemmed from the closet in one of the resident's rooms. She stated that the previous resident, who had since expired, kept food in their closet. The RN stated that the room number was 3A. Record review on 8-22-2023 of the facility's pest control company, August 2023 inspection, dated 8-21-2023, revealed two pages of their recommendations for the facility to prevent pests from entering the building. On…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.