Avir at Woodlands

Inspectors wroteBased on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 7 of 90 (02/02/2025, 02/15/2025, 02/16/2025, 03/01/2025, 03/02/2025, 03/15/2025 and 03/16/2025) days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 02/02/2025, 02/15/2025, 02/16/2025, 03/01/2025, 03/02/2025, 03/15/2025 and 03/16/2025. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ sufficient number of staff to carry out the functions of the food and nutrition service department for 1 of 1 kitchenThe facility failed to ensure there were sufficient number of staff who prepared meals in the kitchen and served cooked food to residents at posted mealtimes. This failure could place residents at risk of not having their nutritional needs met and delay assistance with activities of daily living.

Inspectors wroteBased on observation, interview, and record review the facility failed to employ sufficient staff to carry out the functions of the food and nutrition service department for 1 0f 1 kitchen. The facility failed to ensure that meals were served at the post mealtimes. This failure could place residents at risk of not having their nutritional needs met and delay assistance with activities of daily living.

Inspectors wroteBased on interviews and record review, the facility failed to develop a baseline care plan within 48 hours of a resident's admission that included the instructions needed to provide effective and person-centered care plan and provide a summary of their baseline care plan to residents for 1 (Resident #44) of 5 residents reviewed for baseline care plan completion. The facility failed to complete Resident #44's baseline care plan within the required 48-hour timeframe. This failure could place residents who were newly admitted at risk for not receiving necessary care and services or having important care needs identified.

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 2 of 2 residents (Resident #2, and Resident #6) reviewed for care plans in that:Resident #2 did not have a comprehensive care plan in place that included a code status of do not resuscitate. Resident #6 did not have a comprehensive care plan in place that included use of a trapeze (equipment attached to a resident's bed to aide in independent repositioning). This failure could affect residents by placing them at risk of not receiving individualized care and services to achieve their goals.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the resident's right to be free from neglect for 2 of 14 residents (Resident #10 and Resident #11) reviewed for neglect. The facility failed to ensure Resident #10 was secured with a seatbelt when being transported in the facility van to an appointment in another town approximately 47.5 miles one way on 03/26/2025. Resident #10 fell out of his wheelchair onto the floor of the facility van. The facility failed to ensure Resident #11 was secured with a seatbelt when being transported in the facility van to an appointment in another town approximately 47.5 miles one way on 03/18/2025. An Immediate Jeopardy (IJ) was identified on 03/31/2025. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 3 of 14 (Resident #3, Resident #10 and Resident #11) residents reviewed for supervision. 1. The facility failed to provide supervision for Resident #3, who was care planned for wandering in unsafe places, to prevent him from eloping from the facility on 03/21/2025. The facility was unaware Resident #3 had exited the facility, through his unlocked window in the secure unit. The facility failed to provide adequate supervision in secured locked unit to prevent elopement on 12/05/2024 and 03/23/2025. An Immediate Jeopardy (IJ) was identified on 03/21/2025. [...]

Inspectors wroteBased on observation, 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 with 1 of 13 residents (Resident #3) reviewed for sufficient staffing The facility failed to provide sufficient staffing of Secured Locked Unit for resident with known history of elopement that required 1:1 supervision on 03/24/2025. An Immediate Jeopardy (IJ) was identified on 03/21/2025. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free of unnecessary drugs for 1 (Resident #315) of 18 residents whose medications were reviewed. The facility failed to ensure Resident #315 (a male) received a female hormone replacement drug (Medroxyprogesterone) due to inappropriate sexual behaviors without review for continued necessity and documented rational for the benefit or adequate monitoring from 06/14/2024 until current. This failure could place residents at risk of being over-medicated or experiencing undesirable side effects and cause a physical or psychosocial decline in health.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop a comprehensive person-centered care plan based on assessed needs that includes measurable objectives and timeframes to meet the resident's medical, nursing, mental, and psychosocial needs and describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #41 and Resident #315) of 18 residents reviewed for comprehensive person-centered care plans. The facility failed to ensure Resident #41's comprehensive care plan was person centered and measurable when addressing Residents delusions behavior. The facility failed to ensure Resident #315's comprehensive care plan contained Resident's medication prescribed for the treatment of sexually inappropriate behavior in patients with dementia. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to maintain an environment that was as free from accident hazards as was possible for 2 of 4 (Hall 300 and Hall 400) halls reviewed for accident hazards. The facility failed to ensure a spray bottle of grill and oven cleaner, a bottle of rubbing alcohol, a wire metal brush and a steel wool cleaning pad were stored in a cabinet on Hall 300 that was locked and not accessible to the residents on Hall 300. The facility failed to ensure a bottle of shaving cream, a tube of antifungal powder, a tub of zinc oxide, body lotion, deodorant bottles, and a bottle of shampoo/body wash were stored in a locked shower room and not accessible to the residents on Hall 400. This failure could place residents at risk of injury due to hazardous chemicals.

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 as determined by considering the number, acuity, and diagnoses of the facility's resident population in accordance with the facility assessment for 7 of 10 days reviewed for sufficient staffing. The facility failed to maintain nurse staffing at the level indicated by the PPD budget on 03/23/2024, 05/11/2024, 06/13/2024, 06/18/2024, 07/02/2024, 07/05/2024 and 07/07/2024. This failure could place the residents at risk of resident's needs, safety and psychosocial well-being not being met.

Inspectors wroteBased on record review and interviews, the facility failed to ensure the use of the services of a registered nurse for at least 8 consecutive hours a day, seven days a week for 15 (01/01/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/27/2024, 01/28/2024, 02/03/2024, 02/04/2024, 02/10/2024, 02/11/2024, 02/17/2024, 02/24/2024, 02/25/2024, 03/02/2024 and 03/03/2024) of 91 days reviewed for RN coverage. The facility failed to provide evidence that a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week on 01/01/2024, 01/07/2024, 01/13/2024, 01/14/2024, 01/27/2024, 01/28/2024, 02/03/2024, 02/04/2024, 02/10/2024, 02/11/2024, 02/17/2024, 02/24/2024, 02/25/2024, 03/02/2024 and 03/03/2024. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that each resident received food that is palatable, attractive, and at a safe and appetizing temperature for 1 of 2 lunch meals tested for nutritive value, flavor, and appearance: The facility failed to provide palatable food served at an appetizing temperature to residents, during lunch on 07/08/2024. There were no temperatures logged for the morning meal of 07/08/2024. This failure could affect the residents who ate food from the facility kitchen by placing them at risk of poor food intake and/or dissatisfaction of the meals served.

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. 1. Foods were not sealed and/or labeled properly in dry food storage, refrigerator, and freezer. 2. Ice machine scoop was not stored in proper container while not in use. 3. Hairnets not being worn when needed. 4. Uncovered trash receptacle bin 5. Scoop was left inside the dry storage oatmeal container. 6. Expired food products in the dry storage area. These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses.

Inspectors wroteBased on observations, interviews, record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 1 of 4 hallways (Memory Care Unit) and reviewed for safe, functional, sanitary, and comfortable environment. The facility failed to have residents' environment clean and without damage for 1 (MCU) of 4 hallways. These failures could place residents who reside in the facility in an unsafe and uncomfortable environment.

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 for 1 of 1 kitchen reviewed for food storage. The facility failed to properly store food in the dry food storage, refrigerators and freezer in the kitchen . This failure could place residents at risk for foodborne illnesses.

Inspectors wroteBased on observation, interview and records review the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 2 of 3 patios and 1 of 6 entrance/exit doors reviewed for environment . 1. The facility failed to ensure 2 of 3 non-designated smoking outdoor patios were free of smoke and cigarette butts. 2. The facility failed to ensure smoke did not enter hallway 300 of the nursing facility. These failures could place residents at risk for a clean and comfortable environment.

Inspectors wroteBased on observation, interviews and record reviews the facility failed to ensure food and drink was palatable, attractive, and at a safe and appetizing temperature for 1 of 2 meals reviewed for palatable foods. 1. The facility failed to provide residents who had an altered textured meal with food that was at a safe and appetizing temperature. 2. The facility failed to provide residents with meals that had a palatable flavor. These findings could place residents at risk of poor nutrition and weight loss.

Inspectors wroteBased on observation, interview and record review the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also took into account nonsmoking residents for 1 of 1 smoking area and 2 of 3 patio areas reviewed for smoking. 1. The facility failed to consider nonsmoking resident's exposure to cigarette smoke. 2. The facility failed to maintain nonsmoking areas free of cigarette butts. These failures placed residents at risk of illness and a decline in health.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive person-centered care plan based on assessed needs to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 (Resident #1, Resident #2, and Resident #3) of 3 residents reviewed for comprehensive person-centered care plans. 1. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address type of transfer assistance was required for Resident #1. 2. The facility failed to develop a comprehensive person-centered care plan based on assessed needs to address the use of medroxyprogesterone (female hormone used to lower sex drive in men) as an intervention for inappropriate sexual behaviors for Resident #2. 3. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident's drug regimen was free of significant medication errors for 1 (Resident # 2) of 3 residents reviewed for medications. The facility failed to administer 10 doses of medroxyprogesterone (female hormone used to lower sex drive in men) to Resident #2 due to medication not being available, but MAR indicated 4 of those doses were administered when they were not. The deficient practice placed the residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications. Findings Included: Review of Resident #2's electronic face sheet revealed resident was a [AGE] year-old male who was admitted to the facility on [DATE] with diagnosis to include: Sexual dysfunction, brain damage, and Psychotic disorder with delusions. [...]

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 3 residents (Resident #1) reviewed for accidents and supervision. The facility failed to ensure Resident #1 was free of accidents which resulted in him being dropped due to inappropriate use of assistance devices by NA A. This failure could place residents at risk of injuries.

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 main kitchen and ancillary kitchen reviewed for cold storage. The facility failed to ensure two (2) refrigerators had manual thermometers in them to provide a visual reference of inside temperatures in the event the digital ones failed. These failures could affect all residents in the facility who receive their meals from the facility's kitchen by placing them at risk of acquiring food-borne illness and food contamination.

Inspectors wroteBased on interview and record review the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment and ensure the comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments for 6 (Resident #13, #17, #25, #29, #43, and #52) of 9 residents who were reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan within seven days after the completion of MDS quarterly assessment for Resident's #13, #17, #25, #29, #43, and the annual assessment for #52. [...]

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days a week for 3 of 3 months (October 2022, November 2022, and December 2022) reviewed for RN coverage. The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 13 of 62 days. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 1 of 1 Resident (Resident #110) reviewed for respiratory care. A. The facility failed to ensure Resident #110's oxygen tubing was changed weekly. B. The facility failed to ensure Resident #110's nasal cannula and nebulizer were kept in a bag while not in use. These failures could place residents at risk for infections and transmission of communicable diseases.

Inspectors wroteBased on observation, interview and record review the facility failed to establish and maintain an infection prevention and control program designed to prevent the development and transmission of infection for 1 of 1 staff reviewed for incontinent care (CNA A). CNA A did not perform hygiene and change gloves while providing incontinent care for Resident #53. This deficient practice could place residents at risk for infection, and a decline in health.