Avir at Sealy

In the surveyor’s words

From the most serious findings on record at Avir at Sealy, in the surveyor’s own words.

• No harm, potential for more than minimal, widespreadF812Mar 21, 2025

  Based 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 for 1 of 1 kitchen: A rack for the can goods had an orange brownish substance that had spilled on the rack and on the floor under the rack. The bins with flour had a white residue on the outside of the top and the sugar bin had holes under the handles and there was a black residue on the outside of the bin's top. 3 Shelves in the kitchen that held clean pots and pans were lined with foil and mesh covering on top with a dirty greasy film that covered them. The grill had black grease on the knobs and the fryer was covered with grease and food particles. […]

• No harm, potential for more than minimal, widespreadF727Oct 26, 2022

  Based on interviews and record reviews the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week, for 14 of 26 days (10/5/22 through 10/09/22, 10/12/22 through 10/16/22, 10/19/22 through 10/21/22, and 10/23/22) and designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility. The facility did not provide RN coverage 8 consecutive hours per day, 7 days per week or have a registered nurse employed full time as a DON. This failure could put residents at risk for not receiving care from qualified staff responsible for staff oversight. […]

• No harm, potential for more than minimal, widespreadF865Oct 26, 2022

  Based on interview and record review, the facility failed to maintain documentation and demonstrate evidence of its ongoing QAPI program that includes reports demonstrating systematic identification, reporting, investigation, analysis, and prevention of adverse events; and documentation demonstrating the development, implementation, and evaluation of corrective actions or performance improvement activities. The facility failed to provide documentation that demonstrated evidence of their ongoing QAPI program. This failure could place residents at risk for quality deficiencies being unidentified with no appropriate plans or actions to be developed or implemented. Findings included: Record review on 10/26/22 at 09:21 a.m. […]

• No harm, potential for more than minimal, widespreadF868Oct 26, 2022

  Based on interview and record review, the facility failed to ensure the facility's Quality Assessment and Assurance Committee met quarterly, for 1 of 1 facility, reviewed for QAA/QAPI. The facility failed to ensure they provided documentation showing the QAA/QAPI met for the first quarter (January, February, March) and second quarter (April, May, June) during 2022, to address identified issues and that the DON or RN designee attended. This failure could place residents at risk for quality deficiencies being unidentified and no appropriate plans of actions developed or implemented. Findings included: Record review on 10/26/22 at 09:21 a.m. of Monthly QAPI Meeting agendas and sign in sheets revealed the following: -Sign in sheet dated 03/03/22, for Fourth Quarter Data Oct, Nov, and Dec. […]

• No harm, potential for more than minimal, widespreadF882Oct 26, 2022

  Based on interview and record review, the facility failed to ensure that the designated individual responsible (Infection Preventionist-ICIP) for the infection control program participated on the quality assessment and assurance committee. The facility did not ensure that the ICIP was a member of the facility's quality assessment and assurance committee and reported to the committee on a regular basis. This failure could affect the facilities ability to appropriately recognize and respond to communicable diseases and infections. Findings included: During an entrance interview and observation on 10/24/22 at 11:15 a.m., the ADON said the QAA meetings were held quarterly. […]