Above average — CMS composite of the measures below.
The next survey window likely opens around December 2026
Estimate from public CMS data, current as of July 2026. Survey timing is at the state agency's discretion.
Citation history
Health deficiencies cited at Avir At Itasca during CMS and state inspections, most recent first.
A facility failed to maintain a clean, sanitary, and homelike environment in a secure unit and in a resident’s room. Observations found broken blinds, peeling paint, gouged walls, an uncovered drain opening with gnats, a dirty toilet with urine and brown residue, and broken floor tile covered by a mat near the kitchen entrance. In a resident’s room, three bedside urinals remained full on repeated checks, with urine odor, gnats, and a fly present; staff interviews showed inconsistent expectations for emptying urinals, and the DON stated they should be checked and emptied every 2 to 4 hours.
Kitchen food storage and thermometer sanitization failures were observed. A reach-in refrigerator contained sliced sandwich meat without open or use-by dates, and the dry storage area had spoiled bananas and onions with gnats present. During lunch service, an aide used the same alcohol swab to clean the food thermometer probe between multiple food items, which was identified as a cross-contamination concern.
A resident with paraplegia and multiple foot and ankle wounds received wound care from an RN with the room door open. The RN said the light was out but admitted the door could have been closed and that doing wound care with the door open violated resident privacy. The resident stated the light was working and that staff always leave the door open when treating her feet, while the DON stated the door should be closed for privacy and dignity.
Infection Control Failure During Wound Care: An RN performed wound care for a resident with paraplegia and multiple foot and ankle wounds without first cleaning the work surface or using a barrier, then placed an open wound on the bedsheets and continued care with the door open. The RN acknowledged the wound was contaminated again, and the DON stated nurses were expected to follow the wound care policy and that not following it opens residents up to infection.
Pest control program was not effective when gnats were observed in the kitchen dry storage around spoiled bananas and onions and in a resident's room near three full bedside urinals. The resident reported seeing gnats and flies in the room, and staff acknowledged that spoiled food and unemptied urinals could attract pests and contribute to the odor.
The facility failed to maintain a comfortable temperature in the secure unit, causing discomfort to several residents due to a malfunctioning heating system. Additionally, a resident's room had unrepaired damage, including holes in the drywall and a bent window screen, raising concerns about pest entry and preventing the resident from opening the window for fresh air. These deficiencies compromised the residents' comfort and quality of life.
Two residents' privacy was compromised during wound care treatments when staff failed to properly close curtains and doors, exposing the residents to view by others. Staff interviews confirmed that privacy should be maintained during treatments to prevent embarrassment and loss of dignity, as per facility policy.
A facility failed to accurately reflect a resident's primary diagnosis of orthostatic hypotension in the Quarterly MDS assessment. Despite the resident receiving medication for this condition, the MDS and care plan did not include the diagnosis, potentially affecting care. Staff interviews revealed the omission was a mistake, with the MDS Coordinator acknowledging the error. The facility's policy mandates that MDS assessments align with progress notes and care plans, which was not followed.
A resident's care plan failed to include their primary diagnosis of orthostatic hypotension, despite having a physician's order for midodrine with specific instructions. The omission was acknowledged by facility staff, including the MDS Coordinator, DON, and ADM, who emphasized the importance of accurate care plans. The facility's policy requires care plans to include measurable objectives and timeframes, which was not followed in this instance.
A facility failed to ensure the safe storage of food in a resident's personal refrigerator, which was not monitored for safe temperatures. The resident, with multiple health conditions, had a refrigerator lacking a temperature log, contrary to facility policy. Staff interviews revealed it was the housekeeper's responsibility to document temperatures daily, but this was not done, risking food safety.
A resident with severe cognitive impairment fell and sustained a hip fracture, but the LTC facility failed to notify the family or hospice of the x-ray results and hospital transfer. The LVN assumed the family was aware, and the administrator was unaware of the lapse in communication. The family and hospice only learned of the fracture and transfer after visiting the facility.
Unsafe and Unsanitary Conditions in Secure Unit and Resident Room
Penalty
Summary
The facility failed to provide a safe, clean, comfortable, and homelike environment in the secure unit and in Resident #20’s room. During observation of the secure unit, the dining room had broken blinds on 2 of 5 windows, the community shower bathroom had a brown foul-smelling substance on the toilet seat and urine in the toilet, the floor had an exposed and uncovered sewage drainage hole with gnats flying out of it, the hallway rails had chipped and peeling paint, the walls and room doors had scuffed, peeling paint and gouged sheetrock, and the floor tile at the secure unit entrance was missing and broken with a large black mat covering it. The dietary aide stated the broken floor in front of the kitchen and secure unit had been broken for several months and that meal carts had to be rolled around the mat to keep them from tipping. CNA B stated the dirty toilet could spread germs and cause infection, and that broken blinds, dented drywall, and scratched paint were not homelike. The housekeeper stated all surfaces should be cleaned every day and that the problems in the secure unit did not make for a homelike environment. The Maintenance Director stated new blinds had been ordered but were the wrong size, painting had not been done in about 2 weeks, new flooring was coming, and the shower room drainpipe had a replacement cover available. Resident #20 was a [AGE]-year-old male admitted with paraplegia, edema, immobility syndrome, and anxiety disorder. His quarterly MDS reflected a BIMS score of 15 and independence with bed-to-wheelchair transfers and toilet transfers. On multiple observations, his room had gnats, a urine odor, and three bedside urinals that remained full. The resident was observed in bed with multipodus boots on both legs while gnats were seen around him and around the urinals. A staff member was observed entering and leaving the room without emptying the bedside urinals. The resident stated he usually empties the bedside urinals but had not been able to, and he observed gnats and flies in the room. Staff interviews showed inconsistent understanding of how often bedside urinals should be emptied. CNA E stated full urinals could attract pests and contribute to the foul smell in the room and that they were emptied upon request by the resident. The ADM stated residents who were cognitive and able to move would dump the urinals themselves, but staff should assist if residents requested it or if staff saw they were full. The DON stated her expectation was that bedside urinals be checked and emptied every 2 to 4 hours and that CNAs were responsible for assisting, but when she asked CNAs how often they should be emptied, each gave a different response. The facility policy titled Homelike Environment stated the facility maximizes characteristics that reflect a personalized, homelike setting, including a clean, sanitary, and orderly environment.
Kitchen Food Storage and Thermometer Sanitization Failures
Penalty
Summary
The facility failed to store, prepare, distribute, and serve food in accordance with professional standards in the kitchen. During an initial tour of the kitchen on 01/06/26, surveyors observed one of the two reach-in refrigerators in the dry storage room containing a large zip-sealed bag with smaller prepackaged bags of sliced sandwich meat, and neither the outer bag nor the inner bags had an open date or use-by date. The dry storage room also contained a box of bananas that were dark brown/black and mushy, along with a 50-pound sack of onions that included multiple spoiled, dark black onions and others with approximately 6-inch sprouts. When the onions and bananas were disturbed, a large swarm of gnats was observed flying around the items. In an interview, the DM stated it was her expectation that refrigerated items be labeled and dated to show what the item is, when it was received, when it was opened, and the use-by or expiration date. She also stated it was her expectation that there be no expired items in the kitchen and that spoiled items be discarded, and she identified the unmarked sandwich meat and the spoiled bananas and onions as not meeting those expectations. The DM stated that failing to label items properly or discard spoiled items could result in food reaching residents that could make them sick and could attract pests. On 01/07/26, during lunch service, Dietary Aide A was observed taking temperatures of lunch foods and using the same alcohol swab to clean the food thermometer probe for 3 of 4 food items checked. Dietary Aide A stated that using the same alcohol swab in between foods could have caused cross contamination and had the potential to make residents sick. In a later interview, the DM stated that a new clean alcohol swab should be used each time a food temperature is taken and that using the same swab could result in cross contamination of food.
Wound Care Performed With Door Open
Penalty
Summary
The facility failed to ensure a resident's right to privacy and dignity during wound care when RN A performed treatment with the room door open. Resident #39 was a cognitively impaired [AGE]-year-old female with paraplegia, non-pressure ulcers of the right foot and left foot, and an unspecified open wound to the left ankle. Her quarterly MDS dated 10/10/2025 showed a BIMS score of 7, partial to moderate assistance with bathing, and independence with dressing, and her care plan included wound care for the right heel, left hallux abrasion, and ankle. During observation on 1/7/2026 at 9:13 a.m., RN A provided wound care to the right heel, left hallux abrasion, and ankle with the door open and cleaned all 3 wounds in the same manner. In interview, RN A stated she had done the wound care with the door open because the room light was out, but said she could have closed the door and acknowledged that doing wound care with the door open violated residents' rights to privacy. The resident stated the room light was working and that nurses always leave the door open when they treat her feet, adding that it is probably not a very nice sight if they can see her feet. The DON stated it was her expectation that the door be closed during resident care and that the door must be closed for privacy and dignity.
Infection Control Failure During Wound Care
Penalty
Summary
The facility failed to establish and maintain an infection prevention and control program for Resident #39 during wound care. Resident #39 was a [AGE] year-old female admitted with paraplegia, non-pressure ulcers of the right and left foot, and an open wound to the left ankle. Her quarterly MDS dated 10/10/2025 showed a BIMS score of 7, indicating cognitive impairment, and she required partial to moderate assistance with bathing. Her care plan included wound care for the right heel, left hallux abrasion, and ankle, with an intervention to provide wound care per treatment order. During observation of wound care on 1/7/2026 at 9:13 a.m., RN A opened gauze, calcium alginate, and wound covering on top of her cart before entering the room, without cleaning or disinfecting the surface or placing a barrier down. In the room, RN A put on gloves, removed the old dressings, and laid the open right heel wound on the bedsheets. She then cleansed her hands with wound cleanser, applied gloves, and continued wound care and dressing application. RN A performed the same process for all three wounds and did wound care with the door open. In interview, RN A stated she should not have used wound cleanser to clean her hands, had no alcohol-based hand sanitizer on the cart, forgot to clean her work surface, and acknowledged that laying the wound on the sheet contaminated it again. The DON stated she was responsible for monitoring wound care, expected nurses to follow the wound care policy, and stated that not following the policy opens residents up to infection.
Pest Control Program Not Effective
Penalty
Summary
The facility failed to maintain an effective pest control program to keep the building free of insects and rodents. During observation in the kitchen dry storage room, a swarm of gnats was seen around a box of spoiled bananas and a 50-pound bag of spoiled onions. The Director of Maintenance stated spoiled food should not be stored because it could attract pests and contaminate food, and the Administrator stated the pest issues in the kitchen were not reported to her when first observed. In Resident #20's room, gnats were observed in the room and near three full bedside urinals, and urine odor was noted. On subsequent observations, gnats were still present around the resident and the urinals remained unemptied, and a fly was also seen in the room. The resident stated he had observed the gnats and flies and usually empties the bedside urinals but had not been able to; he also said staff would help if he asked. A CNA stated that not emptying the urinals could attract pests and contribute to the foul smell, and the Maintenance Director stated full bedside urinals and rotting food could attract pests.
Facility Fails to Maintain Comfortable Environment and Room Conditions
Penalty
Summary
The facility failed to maintain a safe, clean, comfortable, and homelike environment for its residents, as evidenced by two main deficiencies. Firstly, the secure unit of the facility was not maintained at a comfortable temperature, causing discomfort to several residents. On the morning of the survey, the thermostat in the secure unit read 67 degrees Fahrenheit, which was below the comfortable range of 71 to 81 degrees Fahrenheit as per the facility's policy. Residents expressed feeling cold, and observations confirmed that the temperature was indeed low, with some residents wearing additional clothing to keep warm. The issue was attributed to a malfunctioning sensor in the heating system, which had been previously serviced but not permanently fixed. Secondly, the facility failed to maintain the physical condition of Resident #7's room, which had two holes in the drywall, scratches in the wall paint, and a bent window screen that did not fit properly. The resident expressed concern about the potential for pests entering through the holes and was unable to open the window for fresh air due to the damaged screen. The maintenance staff acknowledged the issues but indicated that repairs were delayed due to other priorities and an impending renovation. The facility's maintenance log did not reflect any recorded issues with the heater or the damage in Resident #7's room, indicating a lack of documentation and follow-up on these environmental concerns. The administrator and maintenance staff were aware of the temperature issues and had contacted the HVAC company for repairs, but the problem persisted. The facility's failure to address these environmental deficiencies compromised the residents' comfort and quality of life.
Failure to Maintain Resident Privacy During Wound Care
Penalty
Summary
The facility failed to maintain the privacy of two residents during wound care treatments, as observed by surveyors. For Resident #8, the privacy curtain was not fully closed, leaving a gap that allowed a roommate and surveyors to view the resident's uncovered body during treatment. This resident, who has a moderately impaired cognitive ability due to dementia, was exposed during the procedure, which was not corrected until several minutes later. Similarly, for Resident #13, the door was left completely open during wound care, allowing people in the hallway to see the resident. This resident has a severely impaired cognitive ability, and the exposure occurred while the wound dressing on her foot was being changed. Interviews with staff, including a CNA, LVN, the Administrator, and the DON, confirmed that privacy should be protected during all resident treatments by closing curtains, doors, and blinds, and limiting exposure of body areas. The staff acknowledged that the failure to maintain privacy could lead to embarrassment, loss of dignity, and shame for the residents. The facility's policy on dignity, which emphasizes the protection of resident privacy during personal care and treatment procedures, was not adhered to in these instances.
Inaccurate MDS Assessment for Resident with Orthostatic Hypotension
Penalty
Summary
The facility failed to ensure that a resident's Quarterly Minimum Data Set (MDS) assessment accurately reflected the resident's primary diagnosis of orthostatic hypotension. This oversight was identified during a review of the resident's records, which showed that the MDS assessment did not include this critical diagnosis, despite it being a primary condition affecting the resident's health. The resident, an elderly female with severe cognitive impairment, was receiving medication for orthostatic hypotension, as indicated by physician's orders. However, the MDS assessment and care plan did not reflect this diagnosis, which could potentially lead to inadequate care. Interviews with facility staff, including the MDS Coordinator, Director of Nursing (DON), and Administrator (ADM), revealed that the omission was a mistake. The MDS Coordinator acknowledged the error and its potential impact on the resident's care. The DON and ADM both confirmed that the resident's primary diagnosis should have been included in the MDS assessment to ensure accurate care planning. The facility's policy requires that MDS assessments consistently reflect information from progress notes, care plans, and resident observations, which was not adhered to in this case.
Failure to Include Primary Diagnosis in Care Plan
Penalty
Summary
The facility failed to develop and implement a comprehensive person-centered care plan for a resident, which did not include the primary diagnosis of orthostatic hypotension. This oversight was identified during a review of the resident's records, which showed that the care plan, dated August 6, 2024, did not address this primary diagnosis. The resident, an elderly female with severe cognitive impairment, had a physician's order for midodrine to manage her orthostatic hypotension, with specific instructions to keep her sitting or standing for several hours after administration. However, this critical information was not reflected in her care plan, potentially impacting the care she received. Interviews with facility staff, including the MDS Coordinator, DON, and ADM, revealed that the omission was acknowledged, and it was stated that the care plan should have included the resident's primary diagnosis. The MDS Coordinator admitted responsibility for ensuring the care plan was accurate, while the DON and ADM emphasized the importance of reflecting all primary diagnoses in care plans to ensure appropriate care. The facility's policy mandates that care plans include measurable objectives and timeframes to meet residents' needs, which was not adhered to in this case.
Failure to Monitor Resident's In-Room Refrigerator Temperature
Penalty
Summary
The facility failed to ensure the safe and sanitary storage of food items in a resident's personal in-room refrigerator, which was not monitored for safe temperatures. This deficiency was identified for one resident, a female with multiple diagnoses including essential hypertension, major depression disorder, gastro-esophageal reflux disease, and paranoid schizophrenia. The resident's refrigerator lacked a temperature log, which is necessary to ensure that the refrigerator is functioning properly and maintaining safe food storage temperatures. Interviews with staff, including a nursing assistant, housekeeper, director of nursing, and administrator, revealed that it was the housekeeper's responsibility to document the refrigerator's temperature daily. However, the housekeeper could not recall if the temperature log was completed, and the absence of this log was confirmed during observations. The facility's policy requires that refrigerators maintain temperatures at or below 41 degrees Fahrenheit and that monthly tracking sheets are posted to record temperatures, but this was not adhered to in the case of the resident's personal refrigerator.
Failure to Notify Family and Hospice of Resident's Hospital Transfer
Penalty
Summary
The facility failed to notify the resident's representative and hospice agency of a significant change in condition for a resident who experienced a fall resulting in a left hip fracture. The resident, who had severe cognitive impairment and multiple diagnoses including dementia and diabetes, fell on one day, and an x-ray the following day revealed a left hip fracture. Despite the severity of the injury, the family and hospice agency were not informed of the x-ray results or the resident's subsequent transfer to the hospital. The Licensed Vocational Nurse (LVN) involved acknowledged receiving the x-ray results and notifying the doctor, who ordered the resident's transfer to the emergency room. However, the LVN did not notify the family or hospice agency, assuming the family was already aware of the potential need for hospital transfer. The facility's administrator stated that staff were trained to notify families and hospice agencies of any changes in condition or hospital transfers, but was unaware that the notifications had not occurred in this instance. Interviews with the family member and hospice registered nurse (HRN) revealed that they were initially informed of the fall but not of the subsequent x-ray results or hospital transfer. The family member discovered the fracture and hospital transfer only after visiting the facility and noticing the resident's condition. The HRN confirmed that the facility had not communicated the x-ray results or transfer, which prevented the family from making informed medical decisions. The facility's policy required notification of the resident's representative or family in such situations, but this was not followed.
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What surveyors actually found near you
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Resident with a documented fall history left unattended on the patio; found on the ground with a hip fracture.
Walk-in cooler logs missing for 12 days; expired supplements in the medication room fridge.
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Nursing homes near Itasca
How nearby facilities compare on the same public inspection record.
| Facility | Distance | Overall rating | Citations, 12 mo | Serious (J–L) |
|---|---|---|---|---|
| Grandview Nursing And Rehabilitation Center | 8.1 mi | ★★★★★ | 1 | 0 |
| Avir At Hillsboro | 10.2 mi | ★★★★★ | 15 | 0 |
| Town Hall Estates | 10.5 mi | ★★★★★ | 13 | 2 |
| Renaissance Rehabilitation And Healthcare Center | 14.5 mi | ★★★★★ | 4 | 0 |
| Alvarado Meadows Nursing & Rehabilitation | 17.7 mi | ★★★★★ | 4 | 0 |
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Trusted data, never guesswork. Every citation, penalty, rating and Plan of Correction on this page is sourced from public CMS records (latest release July 2026) and official state health department websites.