Avir at Comfort

In the surveyor’s words

From the most serious findings on record at Avir at Comfort, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF727Aug 22, 2025

  Based on interview and record review the facility failed to use the services of a registered professional nurse at least 8 consecutive hours a day, 7 days a week for 1 of 1 facilities reviewed for nursing services. The facility did not utilize the services of an RN on 2/22/25, 2/23/25, 3/1/25, 3/30/25, 4/13/25, 4/20/25, 4/27/25, 5/4/25, 6/1/25, 6/8/25, 6/15/25, 6/29/25, 7/6/25, 7/13/25, 7/20/25, 7/27/25, 8/3/25, 8/10/25, and 8/17/25 for a total of 19 days. This failure could place residents at risk of not receiving needed care and services.The findings were: Review of the PBJ staffing data report for FY quarter 2 2025 (January 1 - March 31) with a run date of 8/14/25 revealed the facility triggered for no RN hours for Saturday 2/22/25, Sunday 2/23/25, Saturday 3/1/25, and Sunday 3/30/25. […]

• No harm, potential for more than minimal, widespreadF725Apr 18, 2025

  Based on interview and record review the facility failed to provide nursing care with a sufficient number of nursing personnel on a 24-hour basis to all residents in accordance with resident care plans for 1 out of 4 days (04/07/25) reviewed for sufficient nursing staff. The facility failed to have sufficient staff available to provide resident care for approximately 5 hours during the 2P-10P shift on 04/07/25. This failure could put residents at risk of not receiving necessary care to maintain their highest practicable physical, mental and psychosocial wellbeing. […]

• No harm, potential for more than minimal, widespreadF812Jun 8, 2023

  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 for 1 of 1 kitchen, in that: 1. The facility failed to ensure the facility fryer was clean and old oil discarded. 2. The facility failed to ensure homemade Jell-O was discarded after 3 days. These deficient practices could place residents who ate food from the kitchen at risk for foodborne illness. The findings were: 1. In an observation on 6/4/2023 at 9:45 a.m. of the facility fryer located in the facility kitchen revealed there were two separate [NAME] with oil. Further inside the oil [NAME] revealed the well on the right was dark and was unable to see the bottom of the pan. […]

• No harm, potential for more than minimal, widespreadF801Aug 24, 2021

  Based on observations, interviews, and record reviews the facility must designate a person to serve as the director of food and nutrition services, for 1 of 1 facility reviewed for qualified dietary staff, in that; The facility did not have a Director of Food and Nutrition Services. This deficient practice placed residents at risk of not having qualified staff to carry out food and nutrition services. The findings included: Observation on 8/23/2021 at 2:00 pm of the facility revealed the Maintenance Director, in the kitchen preparing food for the residents. During an interview on 8/23/2021 at 6:10 pm with the Maintenance Director confirmed he was the cook for the residents due to the facility did not have a Director of Food and Nutrition Services. […]

• No harm, potential for more than minimal, patternF656May 27, 2026

  Based on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident to meet the resident's psychosocial needs for 3 of 3 residents (Residents #1, 2, and 3) reviewed for comprehensive care planning. The facility failed to ensure residents' preferences for activities and leisure were addressed in the comprehensive care plans for Residents #1, 2, and 3. This failure could result in decreased quality of life. Findings included: Record review of Resident #1's Face Sheet reflected a [AGE] year-old female admitted to the facility on [DATE]. Relevant diagnoses included bipolar disorder (a mental health disorder characterized by severe mood swings). […]