Avir at Pilot Point

Inspectors wroteBased on observation, interview, 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 development and transmission of communicable diseases and infections for one (Resident #1) of five residents reviewed for infection control. The facility failed to ensure Resident #1's catheter tubing remained off the floor. This failure placed residents at risk for healthcare associated cross contamination and infections.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one of four residents (Resident #1) reviewed for respiratory care. The facility failed to ensure Resident #1's breathing mask (used to receive medication by breathing in mist through the nose and mouth) was not on the nightstand unbagged on 01/06/2026. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure personal privacy was provided for treatment and confidential records for seven (Resident #3, Resident #17, Resident #27, Resident #29, Resident #43, Resident #54, and Resident #100) of sixteen residents reviewed for Privacy and Confidentiality. 1. The facility failed to ensure LVN B would not check Resident #17's blood sugar and administer her insulin in the hallway on 06/04/2025. 2. The facility failed to ensure LVN A secured Residents #3, #27, #29, #43, #54, and #100's medical information when he left his cart unattended on 06/04/2025. These failures could place the residents at risk of not having their personal privacy maintained during medical treatment and their medical information exposed to unauthorized individuals.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the timeliness of each resident's person-centered, comprehensive care plan, and to ensure that the comprehensive care plan is reviewed and revised by an interdisciplinary team for five (Residents #3 #5, #21, #29, and #50) of twelve residents reviewed for Care Plans Revision. The facility failed to complete a quarterly care plan for Residents #3, #5, #21, #29, and #50. This failure could place the residents at risk of care and needs not being met.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. The facility failed to ensure food being served to residents was covered. This failure could place residents at risk for cross contamination and other air-borne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promotes maintenance or enhancement of his or her quality of life for one (Resident #12) of eight residents reviewed for Dignity. The facility failed to treat Resident #12 with dignity and promote enhancement of his quality of life when the resident was not provided a privacy bag for his catheter bag (collects urine from the urinary bladder) on 06/03/2025. This failure could place residents at risk of not having their right to a dignified existence maintained and a decline in their quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the residents were provided medications and/or biologicals and pharmaceutical services to meet their needs for one (Resident #25) of eight residents reviewed for Pharmaceutical Services. The facility failed to ensure that Resident #25's medications were not left inside the resident's room and that the resident had a physician order for TUMS (antacid used for heartburn and indigestion). These failures could place the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that drugs and biologicals were stored properly in locked compartments for one cart (nurse's cart) of three carts reviewed for Storage of Drugs and Biologicals. The facility failed to ensure that LVN A locked his nurse's cart on 06/04/2025. This failure could place the residents at risk of accessing/opening the cart causing accidental overdose or misuse of medications and not receiving the full benefit of the medication.

Inspectors wroteBased observation, interview, 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 development and transmission of communicable diseases and infections for two (Resident #5 and Resident #21) of eight residents reviewed for Infection Control. 1. The facility failed to ensure CNA D would not place Resident #5's catheter bag (collects urine from the urinary bladder) on the floor while transferring the resident on 06/04/2025. 2. The facility failed to ensure CNA D performed hand hygiene while providing incontinent care to Resident #21 and would not put the gloves that she would use for incontinent care inside her pocket on 06/04/2025. These failures could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, was provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for two (Resident #5 and Resident #9) of two residents reviewed for respiratory care. The facility failed to ensure Resident #5's nasal cannula was changed weekly as per order. The facility failed to ensure Resident #9's nebulizer was changed weekly as per order. These failures could place the residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased observation, interview, and record review, the facility failed to maintain an Infection Prevention and Control Program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 (Resident #4 and Resident #38) of 6 residents observed for infection control. 1. The facility failed to ensure that LVN B changed his gloves and performed hand hygiene while providing colostomy care to Resident #4. 2. The facility failed to ensure CNA C and CNA D sanitized the mechanical lift either before or after use with Resident #38 These failures could place the residents at risk of cross-contamination and the development of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement a comprehensive person-centered care plan for each resident, consistent with the resident rights that included measurable objectives and timeframes to meet the resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #205) of 5 residents reviewed for care plans. The facility failed to provide Resident #205 with a diabetic care plan. This failure could place residents at risk for not receiving care based on their care plans.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated resident allergies, intolerances, and preferences for one (Resident #205) of 5 residents reviewed for food preferences. The facility failed to provide Resident #205 with her preferred diet to address her diabetes. This failure could place residents at risk for malnutrition and poor quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection prevention and control program designated to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable disease and infection for two (Residents #8, #11) of five residents reviewed for infection control. LVN A failed to disinfect the blood pressure cuff in between blood pressure checks for Resident #8 and Resident #11. This failure could place residents at-risk of cross contamination which could result in infections or illness.