Avir at Bellville

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared by methods that conserved nutritive value and flavor and served for palatability for 5 of 5 residents (Residents #17, #26, #30, #41, and #48) reviewed for nutrition.- The facility failed to use nutrient-dense liquids (such as broth or sauces) on 05/06/2026 during lunch preparation by adding water to pureed food to thin tater-tot casserole and bread. These failures place residents at risk for decreased meal consumption, unintentional weight loss and malnutrition, unpalatable food, dehydration, and aspiration pneumonia or choking.

Inspectors wroteBased 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 on 05/05/2026 in 1 of 1 kitchen reviewed for food procurement. - The facility failed to ensure 6-fruit cups and personal size water bottle in 1 of 2 refrigerators were labeled and dated during the initial kitchen tour on 05/05/2026 to identify when the items was placed.- The facility failed to store a clean cooking pot and storage container lid off the floor on 05/05/2026 away from the collection of floor dirt, dust and debris'.- The facility failed to store a used flyswatter on 05/05/2026 away from the servicing and food preparation table. These failures could place residents at risk of exposure to foodborne illness and disease. Findings Include: [...]

Inspectors wroteBased on observation, interview and record review, the facility must dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for garbage disposal. The facility failed to ensure the dumpster door was secured on 1 of 2 dumpster bins during the initial kitchen tour on 05/05/2026. This failure could place residents at risk of exposure to infections, pests and rodents from improperly disposed garbage.

Inspectors wroteBased on interviews and record reviews, the facility failed to maintain the services of a Registered Nurse (RN) for at least 8 consecutive hours a day, 7 days a week, for 25 days (10/05/2024, 10/06/2024, 10/10/2024, 10/11/2024, 10/12/2024, 10/13/2024, 10/14/2024, 10/19/2024, 10/20/2024, 10/21/2024, 10/26/2024, 10/27/2024, 11/02/2024, 11/03/2024, 11/09/2024, 11/10/2024, 11/16/2024, 11/17/2024, 11/23/2024, 11/24/2024, 11/28/2024, 11/30/2024, 12/01/2024, 12/14/2024, and 12/15/2024) of the 6-month review period, reviewed for RN coverage. The facility failed to ensure the facility maintained the required RN coverage for 25 days between October 2024 to March 2025. This failure could place residents at risk of not having their nursing and medical needs met and receiving improper care.

Inspectors wroteBased on observations, interviews, 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 2 of 14 residents (Resident #5 and #97) and 1 of 1 medication room reviewed for pharmacy services. 1. There was one medication (Ketoconazole cream for fungal or yeast infection) expired on 08/2022 found on Resident #5's nightstand in the resident's room on 03/18/2025. 2. Medication aide-B administered Resident #97's Cyclosporine 0.05% eye drop for increasing tear production two drops to the resident's each eye on 03/20/2025. However, the physician order indicated Cyclosporine 0.05% one drop into both eyes. 3. In the medication room, a. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for 1 of 1 kitchen observed for food service. The facility failed to ensure that items stored in the reach-in refrigerator were labeled after opened or prepared. The facility failed to ensure that items stored in the chest freezer were labeled after opened. These failures could place residents who receive food prepared in the facility's only kitchen by placing them at risk for food-borne illness and food contamination.

Inspectors wroteBased on interview and record review the facility failed to develop, implement, and maintain an effective training program for all new and existing staff for 9 (RN E, Dietary Aide F, Housekeeper G, CNA H, Activity Manager I, LVN J, LVN K, LVN L, DON) of 20 employees reviewed for training requirements. The facility failed to implement and maintain a training program that ensured Dietary Aide F and DON received required trainings upon hire. The facility failed to implement and maintain a training program that ensured required trainings were provided to Housekeeper G, CNA H, Activity Manager I, LVN J, LVN K, and LVN L annually. The facility failed to implement and maintain a training program that ensured required trainings were provided to RN E annually. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review the facility failed to include as part of its QAPI program mandatory training that outlines and informs staff of the elements and goals of it's QAPI program for 6 (RN E, Housekeeper G, CNA H, LVN J, LVN L and DON) of 20 employees reviewed for training requirements. The facility failed to ensure required trainings were provided to RN E, Housekeeper G, CNA H, LVN J, LVN L annually. The facility failed to ensure required trainings were provided to the DON upon hire. This failure could place residents at risk of being cared for by staff who have been insufficiently trained.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on ethics training for 3 of 20 employees (Housekeeper G, LVN J, and LVN K) reviewed for training, in that: The facility failed to ensure ethics training was provided to Housekeeper G, LVN J, and LVN K annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide behavioral health training consistent with the requirements at §483.40 and as determined by the facility assessment at §483.71 for 3 of 20 employees (Activity Manager, RN E, LVN L) reviewed for training, in that: The facility failed to ensure behavioral health training was provided to Activity Manager, RN E, LVN L annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the assessment accurately reflected the resident's status for 2 of 14 residents (Residents #11 and #96) reviewed for assessments: 1. Resident #11's significant change MDS, dated [DATE], identified the resident had insulin. However, Resident #11 did not have insulin. 2. Resident #96's admission MDS, dated [DATE], identified the resident was always continent for urinary bladder. However, Resident #96 had an indwelling urinary catheter. This failure could place residents at risk for inadequate care due to inaccurate assessments.

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 timeframes to meet a resident's medical, nursing, and mental needs that were identified in the comprehensive assessment, and described services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 14 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7's care plan reflected her oxygen status and included a care plan regarding how to take care of the resident's oxygen. This failure could place residents at risk for not receiving proper care and services due to inaccurate care plans.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 1 of 3 residents (Resident #16 ) reviewed for incontinence care. When CNA-C was providing incontinent care to Resident #16 on 03/19/2025, the CNA-C did not clean the resident's suprapubic area (the area of the abdomen located below the umbilical region). This failures could place residents who required incontinence care at risk for cross contamination and the development of new or worsening urinary tract infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were fed by enteral means received the appropriate treatment and services to prevent complications of enteral feeding for one (Resident #26) of one resident reviewed for enteral nutrition. When RN-E administered a medication via gastrostomy tube to Resident #26, RN-E did not check residual by aspiration of gastric content of the resident. This failure could place residents with gastrostomy tube at risk for complications, aspiration, and pneumonia.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that licensed staff were able to demonstrate the specific competencies and skill sets necessary to care for resident's needs for 2 of 2 nursing staff (CNA-C and CNA-D) reviewed for competencies. The facility did not perform CNA-C and CNA-D's annual skill check-off. This failure could place the residents at risk for receiving care by staff who do not have the training and competency needed for providing care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities, which involved two residents (Residents #10 and #97) of five residents reviewed for medication errors. 1. Medication aide-B administered fiber laxative calcium polycarbophil 625 mg one tablet for constipation to Resident #10 on 03/19/2025, but the physician order indicated Metamucil (psyllium husk) 0.4-gram one capsule for constipation. 2. Medication aide-B administered Resident #97's Cyclosporine 0.05% eye drop for increasing tear production two drops to the resident's each eye on 03/20/2025. However, the physician order indicated Cyclosporine 0.05% one drop into both eyes. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure all drugs and biologicals were stored in locked compartments for 1 of 14 residents (Resident #5) and 1 nursing carts (C-unit nursing cart) out of 2 nursing carts reviewed for storage. 1. Ketoconazole cream for fungal or yeast infection was found on Resident #5's nightstand in the resident's room on [DATE]. 2. The C-unit nursing cart was left open and unattended by RN -E. These failures could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to enact a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 1 (Resident #13) of 14 residents reviewed, in that: Resident #13's personal refrigerator located in her room observed on 03/18/2025, revealed an unknown food wrapped with papers inside the freezer, with no date and no label. This failure could place residents at risk of foodborne illness due to consuming foods which might be spoiled.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development of communicable diseases and infections for 1 resident (Residents #16) of 5 residents reviewed for infection control practices. When CNA-C was providing perineal care to Resident #16, the CNA-C touched new and clean brief with old and dirty gloves after cleaning the resident's buttock area. This deficient practice placed residents at risk for cross contamination and infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 3 air filters (B-hall air filter) reviewed for environmental concerns. The air filter located B-hall, observed on 03/19/2025, was very dirty with gray colored thickened dust. It was last changed on 04/02/2024. This failure could place residents at risk of a diminished quality of life and respiratory status due to exposure to an environment that is unpleasant, unsanitary, and unsafe.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective training on communications training for 2 of 20 employees (Housekeeper G and LVN K) reviewed for training, in that: The facility failed to ensure effective communication training was provided to Housekeeper G and LVN K annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to include as part of its infection prevention and control program mandatory training that includes the written standards, policies, and procedures for the program for 1 of 20 employees (RN E) reviewed for training, in that: The facility failed to ensure standards, policies, and procedures for an infection prevention and control program training was provided RN E annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on interview and record review, the facility failed to provide mandatory effective in-service training for nurse aides on dementia for 1 of 5 nurse aides (CNA H) reviewed for training, in that: The facility failed to ensure dementia training was provided CNA H annually. This failure could affect residents and place them at risk of being uninformed due to lack of staff training.

Inspectors wroteBased on observation, interview, 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 from 11/1/2023 to 11/30/2023 for a total of 30 days, 12/1/2023 to 12/31/2023 for a total of 31 days and 1/1/2024 to 1/23/2024 for a total of 23 days, reviewed for RN coverage. The facility had no DON from 7/25/2023 to 9/26/2023 and from 12/26/2023 to 1/26/2024. These failures placed the residents at risk for not having decisions made that would have required and RN to make in the management of the resident's healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to properly store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen reviewed. The facility failed to ensure bulk foods were stored in a manner to prevent contamination. The facility failed to ensure foods were sealed and/or labeled properly in refrigerators. The facility failed to ensure refrigerators maintained a temperature at or below 41 degrees Fahrenheit. These failures could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the environment was free of accidents hazards for 4 (Resident #20, Resident #25, Resident #26, Resident #30 ) of 5 residents, reviewed for accidents hazards This failure placed residents at risk of injury for accidents or hazard.

Inspectors wroteBased on observation, record review and interview, the facility failed to employ staff with the appropriate competencies and skills sets to carry out the functions of the food and nutrition service for 4 of 4 dietary support staff Dietary Aide W, [NAME] S, [NAME] R, and Dietary Aide T reviewed for competencies. The facility failed to ensure [NAME] S, [NAME] R, Dietary Aide T, and Dietary Aide W had a current Food Handling Certificate while working in the facility kitchen. This failure could place residents who consume food prepared in the facility kitchen at risk of foodborne illness due to being served by improperly trained staff.

Inspectors wroteBased on observation, interview and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 3 of 13 Residents (Resident #27, #22 and #20) reviewed for environment. The facility failed to properly clean/maintain resident #27, #22 and #20's rooms in a sanitary manner. This failure could place residents at risk of unsanitary conditions, psychosocial decline, spread infections which could result in a decline in health.

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one of five residents (Resident #28) reviewed for care plans The facility failed to ensure Resident #28's comprehensive care plan addressed the residents individual need for the use of a CPAP (a non-invasive ventilation therapy used to facilitate breathing). This failure could place residents at risk of receiving inadequate or unnecessary interventions not individualized to their health care needs. Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted to the facility on [DATE]. [...]

Inspectors wroteBased on record review and interview, 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 resident's choices for 1 of 5 residents (Resident #28) reviewed for Quality of Care in that: -Nurse Aide F provided services outside the scope of practice of a NA by administering a topical medication to Resident #28's wound. -the ADON delegated outside the scope of nursing practice by allowing Nurse Aide F to administer a topical medication to Resident #28's wound. This failure could place residents at risk of inappropriate medication administration, infection and decline in health. Record review of Resident #28's face sheet dated 01/23/2024 revealed a [AGE] year-old male admitted [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure that a resident who needs respiratory care for 1 of 6 residents (Residents #28) reviewed for care consistent with professional standards, in that: The facility failed to clean Resident #28's CPAP (a machine used to keep breathing airway open) mask, nasal pillow and tubing daily. The facility failed to change Resident #28's CPAP tubing monthly. These failures could place residents at risk of respiratory infection, decline in health and hospitalization.