Avir at Burnet

Inspectors wroteBased 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 reviewed for sanitation. The facility failed to properly label food containers stored in refrigerator with contents and use by date. This failure could place residents at risk of foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe and sanitary environment to prevent the development and transmission of communicable diseases and infections for 3 of 7 residents (Resident #36, Resident #49, and Resident #54) reviewed for infection control. CNA B did not change contaminated gloves prior to Resident #49's repositioning; contact with clean supplies; and she did not wash her hands after removing gloves post perineal care. ADON did not sanitize her hands between changing gloves and before exiting a room while performing wound care on Resident #54. LVN A did not sanitize hands after removing gloves and touching medication cart and documenting on the computer after completing blood sugar check on Resident #36. These failures could place the residents at risk of infection transmission, sepsis, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASARR) Level I assessment accurately reflected the resident's status for 2 of 5 residents (Resident #3 and Resident #6) reviewed for PASARR Level I screenings.1. The facility failed to ensure the accuracy of the PASARR Level 1 screening for Resident #3 and Resident #6. The PASARR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis major depressive disorder and bipolar disorder was present upon admission.2. The facility did not complete a 1012 form to update Resident #3 and Resident #6's PASARR Level 1 with the diagnosis. These failures could place residents who had a mental illness at risk of not receiving a needed assessment (PASARR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals for 1 of 3 residents (Resident #32) reviewed for pharmacy services. The facility failed to ensure CMA C administered a correct dose of Cholecalciferol Oral Tablet 10 MCG to Resident #32 for a week without obtaining a correct doze of medication according to the physician order. This failure could place residents at risk for overdosing, delayed healing, and other adverse consequences.

Inspectors wroteBased on observation, interview, and record review, the facility failed to distribute and serve food in accordance with professional standards for food service safety for 1 of 1 kitchen. The facility failed to ensure Dietary Aide A and Dietary Aide B's hair was completely contained with an effective hair restraint. This failure could place residents at risk of being served unsanitary food and foodborne illness. Findings Included: During an observation in the Kitchen on 02/17/25 at 7:35 a.m., Dietary Aide B had approximately 3-4 inches of hair in the nape (back of her head) and wisps of her hair (around front profile of face) not covered with hair net. She was standing at the prep table preparing drinks (milk, juice). [...]

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 1 of 16 residents. (Resident #34) The facility failed to develop an accurate care plan for Resident #34 smoking and renal disease. This failure could place the residents at risk of not receiving care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained free of accident hazards and the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 16 residents (Resident #34) reviewed for accidents and supervision. The facility failed to ensure that Resident #34 did not have cigarettes and a lighter in her purse and in her room. This failure could place residents at risk for injury, harm, and impairment.

Inspectors wroteBased on interview and record review, the facility failed to inform the resident's family and responsible party when there was a change in resident condition for 1 (Resident #1) of 3 Residents reviewed for resident rights. The facility failed to inform Resident #1's family when Resident #1 developed pressure ulcer at her coccyx (commonly referred to as the tailbone, is the final segment of the vertebral column) area on 08/05/2024 and had to be seen by the Wound Care Doctor. This noncompliance was identified as PNC. The deficient practice began on 08/05/24 and ended on 08/26/24. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of their responsible party not being involved in their medical care and treatment.

Inspectors wroteBased on interview, and record review the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections to the extent possible for one (Resident #1) of three residents reviewed for indwelling urinary catheters, in that: The facility failed to ensure Resident #1 had physician orders for her indwelling foley catheter (is a sterile tube that is inserted into your bladder to drain urine) or for care and monitoring. This failure could place residents with indwelling urinary catheters at risk of sepsis, renal failure, urinary tract infections, and pain.

Inspectors wroteBased on observation, interview, and record review, the facility failed to conduct an initial comprehensive, accurate, standardized reproducible assessment of each resident's functional capacity for 1 of 6 residents (Resident #165) reviewed for resident assessments. The facility failed to ensure Resident #165's admission MDS Assessment accurately reflected her receiving hospice services. This failure could place residents at risk of not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being.

Inspectors wroteBased on observation, interview and record review the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food safety in the facility's only kitchen reviewed for dietary services. 1. The facility failed to ensure expired meat and cheese were discarded appropriately. 2. The facility failed to ensure cheese in the kitchen was dated and labeled appropriately. These failures could place residents at risk for food contamination and food-borne illness.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care was provided with such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for three of five residents reviewed (Resident #1, #2, and #3) for respiratory care. 1. The facility failed to ensure Resident #1's humidifier for the oxygen concentrator had water. 2. The facility failed to ensure Resident #1's nebulizer mask was bagged while not in use. 3. The facility failed to ensure Resident #2's oxygen tubing was changed weekly as ordered. 4. The facility failed to ensure Resident #3 had an oxygen sign posted outside her bedroom. These deficient practices could place residents at risk for inadequate care and respiratory infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure that residents received care, consistent with professional standards of care to prevent development or worsening of pressure ulcers for one of 5 (Resident #1) residents reviewed for pressure ulcers. The facility failed to ensure Resident # 1, who transferred from another facility with a pre-existing pressure ulcer, received an initial assessment and a 48-hour initial care plan. The facility failed to ensure Resident #1 received an order for the treatment of a pre-existing pressure ulcers upon admission. The facility failed to ensure Resident #1's pressure ulcer was measured at the initial skin assessment. The facility failed, for the first 4 days of Resident #1's admission at the facility, to administer treatment for her pressure ulcer. [...]