Avir at Pasadena

Based 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 1 of 1 kitchen reviewed for food procurement in that: -Food items expired, and Food items not labeled or dated.These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness and disease.Findings include:Observation of the facility's kitchen and interview on 02/10/26 between 8:23 am and 8:30 am with Dietary [NAME] A revealed the following: A container of what appeared to be beans; it was not labeled or dated in the pantry A container of what appeared to be rice; it was not labeled or dated in the pantryApproximately 42 cups of tea in the refrigerator with no lidsA bag of what appeared to be cabbage that had brown residue in the refrigeratorIn an interview on 02/10/26 at 8:24AM with Dietary [NAME] A, she stated all items were supposed to be labeled with dates and name and she stated, I am about to label it now. When asked additional questions,…

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 provide a safe, clean and comfortable homelike environment for 1 of 8 residents (Resident #11) reviewed for a homelike environment. The facility failed to ensure that Resident #11's room was a clean and comfortable homelike environment.The failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings included: Record review of Resident #11's face sheet dated 2/12/26, revealed the resident was an [AGE] year-old female admitted to the facility on [DATE] with diagnoses including Parkinson's Disease (progressive neurological disorder that primarily affects movement) without Dyskinesia (uncontrollable and involuntary movements). Record review of Resident #11's quarterly MDS dated [DATE], section C revealed a BIMS was not conducted as Resident #11 was rarely or never understood. Observation on 2/10/26 at 9:47 a.m. revealed a brown substance on the bottom edge of the privacy curtain…

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, prepare, distribute, and serve food under sanitary conditions in 1 of 1 preparation kitchen. The facility did not ensure the dishwasher was above the appropriate sanitizing temperature of 120 degrees Fahrenheit. This failure could place residents who ate food from the kitchen at risk of foodborne illness. Findings included: In an observation on 11/20/24 at 1:30 pm, the low temperature dishwasher was observed at 115 degrees Fahrenheit during the rinse cycle, with 100 ppm. In an interview on 11/20/24 at 2:10 p.m., the Dietary Manager stated staff did not let her know the dishwasher was running low temperatures. Staff told her it was not for them to let her know . Maintenance came and looked at the water heater and he mixed up the heater with the laundry. There are two water heaters in the near closet located outside the kitchen. One is for the kitchen and the other one is for the laundry room. He raised it to 140 degrees Fahrenheit. She called corporate to ask where the temperature should be, and they…

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 provide, based on the comprehensive assessment and care plan, activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of each resident for 1 of 6 residents (Residents #81) reviewed for activities, in that: The facility failed to ensure Resident #81 participated in one-on-one in-room activities since January 2024. This deficient practice could place residents at risk of decline in psychosocial well-being and their physical health. Findings included: Record review of Resident #81's Face Sheet dated 8/15/18 revealed she was an [AGE] year-old female admitted to the facility 2/24/23. Her diagnoses included cognitive communication deficit, ataxic gait (a walking abnormality that's characterized by an irregular, clumsy, and wide based walk), depression, muscle wasting and atrophy (loss of muscle mass and strength, often occurring due to lack of use, injury, malnutrition, or certain medical…

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 reviews, 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 2 (Resident #67 and Resident #88) of 5 residents reviewed for infection control. 1. CNA F did not wear appropriate PPE when helping Resident #67, a resident on Enhanced Barrier Precautions, transfer from wheelchair to bed. 2. LVN G did not wear appropriate PPE when she was giving Resident #88, a resident on Enhanced Barrier Precautions, medications through his G-tube (tube into stomach for nutrition). These failures could place residents at risk for cross-contamination, and the spread of infection. Findings include: 1.Record review of Resident #67's undated face sheet revealed he was an [AGE] year-old male admitted on [DATE] with diagnoses of dementia (a decline in mental ability that affects a person's daily life), 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.

Based on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food service safety in 2 of 2 facility refrigerators and 1 of 1 dry food storage areas reviewed for food procurement in that: - The facility failed to label and date food items in the kitchen walk-in refrigerator and resident refrigerator located in the medical records room. - The facility failed to label and date all food items located in the dry food storage area. These failures could affect residents who ate food from the facility kitchen and place them at risk of foodborne illness. Findings include: Observed on 10/10/23 at 8:30 AM an unlabeled plastic gallon zip bag with cooked lima beans and corn and an unlabeled bag of French Fries in walk-in-refrigerator. Interview on 10/10/23 at 8:30 AM, the DM said the unlabeled and undated items in the walk-in refrigerator were items leftover from the previous night. She said the night cook must have forgotten to label them. The DM said that all food should be labeled with the name of the item and the date it…

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 interview and record review the facility failed to implement written policies and procedures that prohibit and prevent residents from abuse, neglect, exploitation, and misappropriation of resident property for 3 (the Administrator, Dietary A, and Housekeeping #A) out of 19 employees reviewed for annual EMR/NAR checks. The facility failed to ensure EMR/NAR checks were completed annually for the Administrator, Dietary A, and Housekeeping #A. The facility failed to keep a copy of the results of the initial and annual searches of the NAR and EMR in the employee's personnel file. This failure could place residents at risk of abuse, neglect, and/or misappropriation of personal property. Findings included: In an interview on 10/12/23 at 09:53 AM, the HR Director said she was responsible for organizing the employee's files and ensuring all the EMR/NAR checks were on the files. She said she completed EMR/NAR when hiring or rehiring an employee. She said she did not know she had to complete the EMR/NAR checks annually. She said she did not know the consequences of not checking the…

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 coordinate assessments with the pre-admission screening and resident review program (PASARR) to the maximum extent practicable for 1 of 6 residents reviewed for PASARR. -Resident #39 had a diagnosis of mental illness and the facility did not coordinate with the appropriate, State-designated authority. This failure could place residents at risk of not receiving needed care and services, causing a possible decline in mental health. Findings include: Review of Resident #39's face sheet, dated 10/11/23, revealed Resident #39 was a [AGE] year-old female, re-admitted to the facility on [DATE] (original admission [DATE]), with the following diagnoses: Type 2 Diabetes Mellitus (impaired use of the body's blood sugar), bipolar disorder (a serious mental illness characterized by extreme mood swings), major depressive disorder, recurrent (episodes of depression), end stage renal disease on hemodialysis (loss of kidney function requiring kidney replacement…

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, record review and interview, the facility failed to follow written policies on permitting residents to return to the facility after they were hospitalized or placed on therapeutic leave for 1 of 2 closed Records (CR #1) reviewed. 1. The facility failed to readmit CR #1 after he was hospitalized . This failure could place residents, who transfer to the hospital, at risk of being denied readmission to the facility. Findings include: Observation of the facility on 06/26/23 at 12:15PM, revealed CR #1 was not in the facility. Record review of CR #1's undated face sheet revealed he was [AGE] year-old male admitted to the facility on [DATE]. His diagnoses included, heart disease, essential hypertension (High blood pressure), lack of coordination cerebral infarction, dementia, psychotic disturbance, mood disturbance, and anxiety. Record review of CR #1's nurse note dated 1/2023 read in part- : 1200- transportation EMS transportation scheduled for resident to go to Local Hospital ER. ETA 1 hour.…

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.