Avir at Stephenville

Inspectors wroteBased on interviews, and record review, the facility failed to incorporate recommendations from a PASRR (Preadmission Screening and Resident Review) evaluation report into a resident assessment, care planning, and transition of care for one (Resident # 9) of two residents reviewed for PASRR services. The facility failed to submit a complete and accurate request for NFSS in the LTC online portal within 20 days after the IDT meeting For resident #9. This failure could place residents who were PASRR positive at risk of not getting the PASRR services for a better quality of life and could lead to a decline in health.

Inspectors wroteBased on interview, and record review the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs) to meet the needs for 1 of 5 residents (Resident #4) reviewed for pharmaceutical services, in that: The facility failed to reorder medication for Resident #4 before his supply was depleted. These failures could place residents who receive medications at risk for a decline in health and of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be informed of, and participate in, his or her treatment including the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he/ she preferred for 1 of 4 residents (Resident #406) reviewed for medication consents. The facility failed to ensure Resident #406 or their representative signed consent for hormone medication medroxyprogesterone acetate (Provera) (a female hormone prescribed to women to prevent pregnancy, hormone replacement therapy and management of abnormal uterine bleeding. When prescribed to men, the medication reduced testosterone levels, lowering sexual drive) prior to administering the medication. [...]

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 time frames to meet, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 3 residents (Resident #5, Resident #20 and Resident #53) reviewed for care plans in that: The facility failed to ensure Resident #5 had a care plan in place for use of a mechanical lift. The facility failed to ensure Resident #20 had a care plan in place for use of a mechanical lift. The facility failed to ensure Resident #53 had a care plan in place for hospice services. This failure could affect residents by placing them at risk of not receiving individualized care and services to meet their needs safely.

Inspectors wroteBased on interview and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician and others participating in the provision of care for 1 (Resident #53) of 4 residents reviewed for hospice services. The facility failed to maintain required hospice forms and documentation, that included:*the certificate of terminal illness and the hospice election form; *how the communication will be documented between the facility and the hospice provider; and *the physician certification and recertification of the terminal illness. [...]

Inspectors wroteBased on observations, interviews and record reviews, 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 3 of 4 (CNA-A, CNA-B, and CNA-C) staff observed during incontinent care. The facility failed to ensure that staff (CNA-A, CNA-B and CNA-C) performed proper peri-care (incontinent care) for Resident #1 and Resident #2. These failures placed residents of the facility at risk of infections from incontinent care.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure the resident had a right to a safe, clean, comfortable, and homelike environment for 2 ( Resident #8 and Resident #10) of 6 residents reviewed for rights in that: 1. Resident #8's bathroom was observed to be unsafe and unsanitary. 2. Resident #8 and Resident #10 complained of roaches in their rooms and bathrooms. This deficient practice could place residents at risk of living in an unsanitary environment, and psychosocial harm due to diminished quality of life.

Inspectors wroteBased on observation, interviews and record reviews, the facility failed to ensure the resident environment remains free of accident hazards as possible 2 (Resident #7 and Resident #8) of 6 reviewed for accidents The DON brought a dog to work at the facility that bit Resident #7 on the ankle and was aggressive toward Resident #8. This was determined at no actual harm with the potential for more than minimal harm at past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the investigation dated on 07/08/2024 when staff were in-serviced no dogs were allowed at the facility. This deficient practice could place residents at risk of an unsafe environment that could lead to a diminished quality of life.

Inspectors wroteBased on interview and record reviews the facility failed to ensure resident had the right to be free from abuse for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect. The facility failed to prevent CNA D from verbally abusing Resident #4 and Resident #5 on 07/04/2024 witnessed by RN C when she yelled, screamed, and slammed the door. These failures could place residents at risk of fear, emotional distress, and decreased quality of life, and further abuse.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure that all alleged violations involving abuse are reported immediately, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect. The facility failed to report to the Health and Human Services Commission State Survey Agency and other officials when an alleged allegation of verbal abuse was reported by RN C when she witnessed CNA D verbally abuse Resident # on 07/04/2024. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to have evidence that all violations in response to abuse, neglect, exploitation, or mistreatment, were thoroughly investigated for 2 (Resident #4 and Resident #5) of 7 residents reviewed for abuse and neglect. The facility failed to investigate the allegation of verbal abuse by CNA D on 07/04/2024 towards Resident #4 and Resident #5 witnessed by RN C. The failure could place residents at risk of allegation of abuse not being thoroughly investigated and at risk of ongoing abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received parenteral fluids administered consistent with professional standards of practice and in accordance with physician orders for 1 of 1 resident (Resident #7) reviewed for peripheral intravenous care. 1. The facility failed to ensure LVN A administered Resident #7's IV (intravenous) antibiotics consistent with professional standards of practice and in accordance with physician orders. 2. The facility did not ensure Residents #7's central line dressings were changed per the physician's order. 3. The facility failed to draw labs weekly per physician orders while Resident #7 was on IV antibiotics. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:23 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of significant medication errors for 2 of 2 residents (Resident #7 and #51) reviewed for medication errors. The facility failed to administer Resident #7's IV (intravenous) antibiotics as ordered by the physician on [DATE], [DATE] (two doses), [DATE], and [DATE]. An Immediate Jeopardy (IJ) was identified on [DATE] at 3:23 p.m. While the IJ was lowered on [DATE] at 11:22 p.m., the facility remained out of compliance at a severity level of no actual harm with a scope of pattern, due to the facility's need to evaluate the effectiveness of their corrective actions. The facility failed to ensure nursing staff administered Resident #51's Insulin Glargine as ordered by the physician. [...]

Inspectors wroteBased on record review and interview the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 4 (Resident #2, Resident #7, Resident #28, Resident #51) of 18 residents reviewed for comprehensive care plans. The facility failed to develop a PASRR care plan Resident #2. The facility failed to develop care plan goals for Resident #28 related to his ADL Functions. The facility failed to ensure LVN N administered Resident #51's Insulin Glargine 7 times during a 2-month review period, per physician order. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and/or the residents' goals and preferences, for 1 of 18 residents (Residents #70) reviewed for respiratory care. The facility failed to ensure that Residents #70's oxygen tubing had been changed and dated once weekly. This failure placed residents that used oxygen/treatments at risk of respiratory complications and/or possible respiratory infections.

Inspectors wroteBased on interviews and record reviews the facility failed to ensure physician visits were conducted once every 30 days for 2 of 18 residents (Resident #2, Resident #73) and every 60 days for 4 of 18 residents (Resident #25, Resident #46, Resident #51, Resident #56) who were reviewed for physician visits. The facility failed to have Resident #2 seen by physician at least once every 30 days for the first 90 days after admission on [DATE]. The facility failed to provide documentation that Resident #2 was seen in April 2024. The facility failed to have Resident #73 seen by physician at least once every 30 days for the first 90 days after admission on [DATE]. The facility failed to provide documentation that Resident #73 was seen in March 2024, April 2024 and May 2024. [...]

Inspectors wroteBased on interviews, and record review the facility failed to have sufficient nursing staff to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident and determined by considering the number, acuity, and diagnoses of the facility's resident population with accordance for 3 of 10 days reviewed for sufficient staffing. The facility failed to maintain nurse staffing at the level indicated by the PPD budget on 05/04/2024, 05/12/2024 and 06/01/2024. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 3 of 6 (Medication Cart 1, 2 and 3) reviewed for medication storage. The facility failed to keep each resident's medications in their original containers/packaging. This failure could result in drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 18 residents (Resident #4) reviewed for resident rights. The facility failed to ensure staff treated Resident #4 with respect and dignity while performing wound care without the privacy curtain being pulled. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide services related to protecting the resident's privacy for 1 (Resident #28) of 18 residents reviewed for resident rights. 1. The facility failed to ensure staff treated Resident #28 with respect and dignity while performing peri-care without the privacy curtain being pulled. 2. The facility failed to ensure staff treated Resident #28 with respect and dignity while performing transferring of Resident from bed to chair with a Hoyer Lift without the privacy curtain being pulled. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 1 resident (Resident #28) reviewed for accidents and supervision. The facility failed to ensure CNA and NA locked (legs MUST BE in the maximum OPENED/LOCKED position) the Hoyer (mechanical) lift during the transfer of Resident #28. This failure could place residents at risk of injuries.

Inspectors wroteBased on observations, interviews and record reviews, 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 of 4 (CNA L and NA) staff observed during incontinent care. The facility failed to ensure that staff (CNA L and NA) performed proper peri-care (incontinent care) or proper hand hygiene for Resident #28. These failures placed residents of the facility at risk of infections from incontinent care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store medications in a locked compartment for 2 of 3 (Hall 3 Medication Cart and Hall 5 Medication Cart) medication carts reviewed for medication storage. The facility failed to keep each resident's drugs in their original containers/packaging. These failures could place all residents at risk of harm or decline in health due to lack of potency of supplies, medications/biologicals or misappropriation of medications, or drug diversions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat residents with respect, dignity, and care for each resident in a manner that promotes maintenance or enhancement of his or her quality of life for 1 of 1 residents (Resident #1) reviewed for dignity. The facility failed to ensure Resident #1 was allowed to smoke as according to his request and smoking assessment. This failure could place residents at risk of a diminished quality of life and lead to a loss of self-esteem and isolation.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' mental and psychosocial needs for 1 of 2 (Resident # 1) residents reviewed for care plan completion. The facility failed to ensure Resident #1 had a comprehensive care plan with measurable objective and person-centered interventions specific to smoking safety and elopement. This failure could place residents at risk for not receiving appropriate supervision.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide an ongoing program of activities designed to meet the interests and the physical, mental, and psychosocial well-being for 4 of 13 residents (#6, #7, #8, #9) on the Secure Unit reviewed for activities, in that 1. Resident #6, #7, #8, #9 did not have an ongoing activity program designed to meet her interests. This deficient practice placed residents on the Secure unit at risk for isolation, low self-esteem, and decline in mental status. Finding Include: 1. Review Resident #6 face sheet dated 12/15/23 revealed an [AGE] year-old female, admitted to facility on 1/7/21 with diagnoses that included Gastrointestinal hemorrhage (bleeding in the gastrointestinal tract), Alzheimer's disease (neurodegenerative disease). [...]

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 3 of 6 (room [ROOM NUMBER], #204 and #206) rooms in the secure unit observed for environment. The window blind blades (white 2-inch vinyl blades) were broken or missing in residents' rooms #202, #204 and #206. This failure could place residents at risk for diminished quality of life due to the lack of a well-kept environment .

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the residents who need respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-center care plan, the residents' goals, and preferences for 2 of 4 residents (Resident #11, Resident #13) reviewed for quality of care. The facility failed to ensure Resident #11 and Resident #13's nebulizer cup and tubing was kept in bag while not in use. This failure could place residents at risk for respiratory infections.

Inspectors wroteBased on interview and record review the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week in that: The facility had no RN coverage on 03/20/2022, 06/18/2022, 06/19/2022, 08/21/2022, 01/01/2023, 01/29/2023, and 03/25/2023. The facility had less than 8 consecutive hours of RN coverage on 04/30/2022, 05/22/2022, 08/28/2022, 10/30/2022, 04/14/2023, and 04/22/2023. This failure could affect residents at the facility by placing them at risk for not having their nursing and medical needs met. Findings Included: [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure the menu was followed, for 3 (Resident # 11, Resident #14 and Resident #53) of 13 residents observed during lunch meal on 04/25/2023. The facility failed to ensure Resident # 11, Resident #14 and Resident #53 received a garlic bread stick or an approved alternative during the lunch meal. This failure could place residents that eat out of the kitchen at risk of poor intake, chemical imbalance and/or weight loss.

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 foods were sealed and/or labeled properly in refrigerator. The facility failed to ensure foods were sealed and/or labeled properly in dry storage. The facility failed to ensure all food was not past expiration date. These failures could place residents that eat from the kitchen at risk for food borne illnesses.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 8 staff reviewed for infection control procedures. Facility staff failed to wear facemasks that covered the nose and mouth at all times when in the presence of residents. These failures could place residents at risk for the transmission of communicable diseases.

Inspectors wroteBased on observation , interview and record review, the facility failed to thoroughly investigate an allegation of abuse for 2 (Resident # 57 and Resident # 35) of 18 residents reviewed for abuse. The facility failed to complete a thorough investigation and maintain documentation that an allegation of abuse for Resident #57 and Resident #35 were thoroughly investigated. This failure could place residents who report allegations of abuse at risk of not being thoroughly investigated.