Avir at Stephenville

In the surveyor’s words

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

• Immediate jeopardy, patternF694Jun 14, 2024

  Based 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. […]

• Immediate jeopardy, patternF760Jun 14, 2024

  Based 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. […]

• No harm, potential for more than minimal, widespreadF727Aug 20, 2026

  Based on interview and record review, the facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents for 6 (07/30/2026, 08/10/2026, 08/11/2026, 08/14/2026, 08/15/2026, and 08/16/2026) of 30 days (07/21/2026 - 08/20/2026) reviewed for DON coverage. The facility failed to ensure the DON did not serve as a charge nurse when the facility had an average daily occupancy of 60 or more residents on 07/30/2026, 08/10/2026, 08/11/2026, 08/14/2026, 08/15/2026, and 08/16/2026. This failure leaves residents without the nursing administrative oversight that only the DON can provide. Findings included: Record review of facility document titled, daily nurse staffing, dated 07/30/2026, reflected a daily census of 70. […]

• No harm, potential for more than minimal, widespreadF801Mar 10, 2022

  Based on interview and record review, the facility failed to employ sufficient staff with the appropriate competencies, and skills set to carry out the functions of the food and nutrition service for 1 of 1 (Dietary Manager) reviewed for qualified dietary staff. The facility failed to ensure the facility's Dietary Manager (DM) met the requirements for a certified dietary manager. This failure could place residents at risk of not having their nutritional needs met and place them at risk for food born illnesses. Findings included: Record review of DM's personnel file revealed a hire date of 11/08/2021. […]

• No harm, potential for more than minimal, widespreadF802Mar 10, 2022

  Based on observation, interview, and record review the facility failed to employ sufficient staff with the appropriate competencies, skills set and accreditations to carry out the functions of the food and nutrition service department for 4 of 11 dietary staff (Dietary Cook 1, Dietary Cook 2, MS, and CNA D) reviewed for dietary support personnel. The facility failed to ensure that dietary staff (Dietary Cook 1, Dietary Cook 2, MS, and CNA D) serving in kitchen were working with current Food Handler Certificate. […]