Avir at Sweetwater

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure all Pre-admission Screening and Resident Review (PASRR) Level I residents with mental illness were provided with an accurate PASRR Level I for 3 of 24 residents (Resident #9, Resident #17, and Resident #18 ) reviewed for PASRR screening, in that: Resident #9 did not have an accurate and updated PASRR Level 1 assessment, reflecting a diagnosis of mental illness. Resident #17 did not have an accurate and updated PASRR Level 1 assessment, reflecting a diagnosis of mental illness. Resident #18 did not have an accurate and updated PASRR Level 1 assessment, reflecting a diagnosis of mental illness. This failure could place residents, with an inaccurate PASRR Level 1 and no PASRR Level 2 Evaluation, at risk for not receiving care and services to meet their needs.

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 in 1 of 1 kitchen reviewed for dietary services, in that:The facility failed to ensure frozen french fries were stored in a sealed, dated, and labelled freezer-safe bag in the freezer. The facility failed to ensure frozen tator tots were stored in a sealed, dated, and labelled freezer-safe bag in the freezer. The facility failed to ensure a container of parmesan cheese contained an expiration/use by date after opening and was discarded by that date. The facility failed to ensure a container of processed, sliced strawberries contained an expiration/use by date after opening and was discarded by that date. The facility failed to ensure a container of prepared sloppy joe mix was discarded by the use by date. [...]

Inspectors wroteBased on interview and record review, the facility failed to follow their own established smoking policy for 5 of 6 residents reviewed for smoking. (Resident #11, #21, #29, #35, #38)The facility failed to follow smoking policy and complete smoking assessments quarterly for the following Residents #11, #21, #29, #35, #38. This failure could place residents at risk of injury or harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident's right to a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 24 resident bathrooms (Resident #3) in that: The bathroom sink in Resident #3's room was broken and detached from the wall. This failure could lead to residents experiencing a diminished quality of life and could place residents at risk for injuries.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure all drugs and biologicals were stored in accordance with currently accepted professional principles and failed to store in a separate locked, permanently affixed compartment for storage of controlled drugs for 1 of 1 discontinued medication storage closet (ADON Office) reviewed for storage of discontinued drugs. The Facility failed to store discontinued narcotic medications under double lock. This deficient practice could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure information on how to file a grievance or complaint was available to the residents for 7 of 7 confidential residents reviewed for grievances. The facility failed to provide a prominent posting of the Grievance Procedure, access to Grievance forms, information of who the facility's grievance official was and their contact information, information of how a resident could file an anonymous grievance, and the residents' right to obtain a written decision related to their grievance. This failure could place residents at risk of unresolved grievances and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to resident or family group, if one exists, with private space, and take responsible steps, with the approval of the group, to make residents and family members aware of upcoming meetings in a timely manner for seven of seven anonymous residents reviewed for resident family group and response. The facility did not provide a private space for resident council meetings. This failure could place residents at risk of not being able to exercise their rights of being able to voice their grievances in private, without uninvited staff being present. Findings Included: Observation and interviews on 12/16/2024 at 10:30 AM during a Resident Council meeting held during survey, revealed the following: The Resident Council meeting was held in the dining room. The area had two open doorways that did not have a door closure. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received and the facility provided food that was palatable, attractive and at a safe, and appetizing temperature for 3 of 3 food forms (Regular, Mechanical Soft, and Pureed) for 1 of 1 meal reviewed for palatability. 1) The facility failed to provide food that was palatable for 3 of 3 food forms served (Regular, Mechanical Soft, and Puree) at 1 of 1 meal observed (12/16/24 lunch). This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

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 in 1 of 1 kitchen reviewed for dietary services. 1) The facility failed to keep freezer handles clean. 2) The facility failed to properly store food in the freezer and refrigerator. 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 that its medication error rate was not 5 percent or greater. The facility had a medication error rate of 7.69% based on 2 errors out of 26 opportunities, which involved 2 of 10 residents (Resident #202 and Resident #2) reviewed for medication administration. 1. LVN A failed to administer Midodrine (given for low blood pressure) to Resident #202, according to physician orders. 2. LVN A failed to administer Tylenol (given for pain) to Resident #2, according to physician orders. These failures could place residents at risk of incomplete therapeutic outcomes, increased negative side effects, and decline in health.

Inspectors wroteBased on observation, interview 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 and transmission of communicable diseases and infections for 1 of 5 residents (Resident #41) and 2 of 5 staff (CNA A, and CNA B) reviewed for infection control. CNA A and CNA B failed to wear proper PPE when providing direct care for Resident #41 who was on Enhanced Barrier Precautions.

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 in 1 of 1 kitchen reviewed for dietary services, in that: The facility failed to ensure to date and label all food (DM). Dietary staff failed to cover food that was not actively being served (DM, Dietary [NAME] and Dietary Aide) Dietary staff exposed the lip of clean cups to the bottom of a tray that could potentially be contaminated and used them to serve hydration to residents (Dietary Aide) The Dietary [NAME] did not allow the puree machine to air dry after running it through the dishwasher prior to preparing residents meal. The Dietary [NAME] and Aide failed to wash their hands for the recommended time (20 seconds) and after glove changes. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents had the right to formulate an advance directive for 4 of 16 residents (Residents #24, #33, #37, and #40) reviewed for advanced directives, in that: Residents #24, #33, #37, and #40 were listed as a DNR (Do Not Resuscitate) but had Out-of-Hospital Do Not Resuscitate (OOH-DNR) forms that were incorrectly filled out or missing required information. These failures could place residents at risk for not having their end of life wishes honored and incomplete records.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain and ensure safe and sanitary storage of residents' food items for 5 of 15 refrigerators reviewed for food safety (Resident #7, #8, #13, #35 and #40) in that: (Resident #7) room [ROOM NUMBER]contained a resident refrigerator that did not have a temperature log attached to the refrigerator. The contents of refrigerator had unlabeled food and a thermometer that displayed a temperature greater than 41 degrees Fahrenheit. (Resident #35) room [ROOM NUMBER] contained a resident refrigerator that had temperature log attached to the refrigerator that displayed documented temperatures greater than 41 degrees Fahrenheit. The contents of refrigerator had unlabeled food. There was no thermometer in the refrigerator or the freezer. [...]

Inspectors wroteBased on interviews and record reviews the facility failed to ensure the residents had the right to participate in, his or her treatment which included 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 or she preferred, for 2 of 14 residents ( Resident #33 and #38) reviewed for resident rights . The facility failed to obtain a signed informed consent based on information of the benefits, risks, and options available for Residents #33 and #38 prior to administering Lorazepam (anti-anxiety medication). [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure PRN orders for psychotropic drugs were limited to 14 days unless the attending physician or prescribing practitioner believed, and documented, that it was appropriate for the PRN order to be extended beyond 14 days, for 2 of 14 residents (Resident #33 and #38) reviewed for PRN psychotropic medications. Resident #33 and #38 continued to have a PRN order for Lorazepam 0.5mg after 14 days without an evaluation by the physician for continued treatment. This failure could result in residents receiving psychotropic and antipsychotic medications when contraindicated and could also result in residents experiencing adverse drug reactions.