Avir at Hillview

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice for 2 (Resident #1 and #2) of 4 residents reviewed for quality of care. 1. The facility failed to ensure staff conducted neurological assessments on Resident #1 after his unwitnessed fall on 12/05/24. 2. The facility failed to ensure staff conducted neurological assessments on Resident #2 after her unwitnessed fall on 01/31/25. These deficient practices could place residents at risk of head injuries, brain bleed and developing undiagnosed conditions.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with profession standards for food safety for 1 of 1 kitchen reviewed for food and safety and sanitation. 1. The facility failed to ensure dietary staff practiced proper hand hygiene and glove use. 2. The facility failed to seal, label, and date tortillas and failed to label and date two large bags of ice-covered chicken in one of one freezer located in the dry storage area. These failures could place residents at risks for health complications and foodborne illnesses.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment for the 27 residents, in the memory care unit, reviewed for a safe, clean, comfortable, and homelike environment The facility failed to report maintenance issues to the MNTD and make repairs to a loose hand railing, in the memory care unit community bathroom . This failure could have placed the residents in the memory care unit to falls.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents unable to conduct activities of daily living (ADLs) received the necessary services to maintain good grooming and personal hygiene for four of eight residents (Resident # 23, Resident # 29, and Resident #104) reviewed quality of life. The facility failed to ensure Resident #23's, Resident #29's, and Resident #104's nails were cleaned. These failures could place residents at risk for poor hygiene, dignity issues, and decreased quality of life. 1. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a therapeutic diet was prescribed by the attending physician for 3 of 13 residents (Resident #18, Resident #26, and Resident 30) reviewed for dietary services. The facility failed to ensure Resident #18, Resident #26, and Resident #30 received their prescribed diet for 09/24/2024 lunch. This deficient practice could place residents, who were provided a mechanically altered diet, at risk of choking, aspiration (inhaling food,) and diminished quality of life. Resident #18 Record review or Resident #18's AR, dated 09/24/2024, reflected an [AGE] year-old man, born on 7/11/1942, who admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the transmission of communicable diseases and infections for 5 of 5 resident (Resident #20, #22, #32, #33, and #42) reviewed for infection control. The facility failed to ensure MA performed proper hand hygiene when passing medications on Residents #20, #32, and # 33. The facility failed to ensure CNA-A and CNA-B sanitized equipment between residents. This failure could place residents at risk for development of communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to provide advance notice of change in services and charges not covered under Medicare for 2 of 3 residents (Residents #27 and Resident #28) reviewed for Medicaid and Medicare Coverage Liability Notices. 1. The facility failed to ensure Resident #27 was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNF ABN) when he was discharged from Medicare Part A skilled nursing services. 2. The facility failed to ensure Resident #28 was provided a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage Form CMS-10055 (SNF ABN) when he was discharged from Medicare Part A skilled nursing services. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to adequately equipp residents the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, from the bathroom for 2 of 8 Residents (Resident #4 and Resident #50) who were reviewed for resident call systems. The facility failed to ensure Resident #4 and Resident #50's shared bathroom had a pull string attached to the call light switch making the call light button accessible if the resident were lying on the floor. This failure could place residents at risk of harm by not being able to call for help when needed.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure the residents right to be free from misappropriation of property for 1 (Resident #1) of 6 residents reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #1's Ondansetron (generic Zofran), a medication used to treat nausea by CMA-A. This failure placed the resident at risk of not receiving the prescribed medication.

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. The facility failed to ensure injectable insulin of the staff was not stored with food items in the refrigerator. The facility failed to ensure food items in the refrigerator were not expired. These failures could place residents at risk for transmittable diseases, food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who used psychotropic drugs received gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs for one (Resident #02) of two residents reviewed for unnecessary medications. The facility failed to attempt a gradual dose reduction (GDR) for Resident #02's Clonazepam . These failures could place residents at risk for possible adverse side effects, adverse consequences, decreased quality of life and dependence on unnecessary medications.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 4 of 7 residents (Residents #39, #36, #15 and #17) reviewed for infection control in that: a) LVN A and MA A did not clean and disinfect the wrist blood pressure monitor when it was used on Resident #39, Resident #36, and Resident #15. b) NA A and NA B used soiled gloves for handling clean gloves while providing incontinent care for Resident #17. These failures could place the residents at the facility at risk of transmission of diseases and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or other residents for 1 of 8 residents (Resident #1 and #3), reviewed for a call light system, in that: The facility failed to ensure Resident #1 and Resident #3's call buttons were accessible in the event of an emergency or to meet care needs. This failure could affect residents by not having access to call for assistance resulting in needs not being met.

Inspectors wroteResident #5 Based on observation, interview, and record review, the facility failed to ensure that residents who need respiratory care were provided such care consistent with professional standards of practice for 1 out of 1 resident (Residents #05) reviewed for respiratory care. The facility failed to change and/or label Resident # 05's oxygen equipment per the facility policy and procedure. This failure has the potential to affect residents by placing them at risk for infections and complications associated with respiratory equipment failure due to exposure to equipment that has been used for an amount of time beyond appropriate or intended use limits.