Avir at Baird

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based 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 12 months ([DATE], [DATE], and [DATE]) reviewed for RN coverage.The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 5 days of 90 days in [DATE], [DATE], and [DATE]. This failure could place the residents at risk of 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 the direct care staff.Findings included: Record review 2/11/26 of the CMS' PBJ Staffing Data Report, (payroll-based journal nurse staffing and non-nurse staffing datasets provide information submitted by nursing homes including rehabilitation services on a quarterly basis) FY Quarter 1 and 2, revealed partial or no evidence of RN coverage for 5 of 90 days: 1. 11/1/2025 with no RN coverage.2. 11/16/2025 with no RN coverage. 3. 11/22/2025 with no…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care for 2 Nurse Aides (NA A and NA B) of 4 nurse aides reviewed for proficiency of nurse aides. The facility failed to ensure NA A and NA B were CNAs after four months of being hired. This failure could place residents at risk of not being provided care by qualified staff, which could cause inadequate care and injury resulting in decreased health and psycho-social well-being. Findings include:1. Record review of NA A's employee record revealed she was hired 03/1/25 as a Nurse Aide trainee. Her Texas Performance Nurse Aide Program training was completed on 03/30/25, and NA A completed skills checkoffs on resident care and services. There was no proof of her being a Certified Nurse Assistant. Record review of NA A's Timesheet at [This Facility] revealed her date of hire was 03/1/25 and started working regular hours on 03/1/25. NA…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based observation, interview, and record review, the facility failed to establish and 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 one (Resident #1) of 2 residents reviewed for Infection Control. The facility failed to ensure NA A performed hand hygiene and glove change while providing incontinent care to Resident #1 on 02/8/26. This failure could place residents at risk of cross-contamination and development of infections.Findings included:Record review of Resident #1's Face Sheet, dated 2/8/26 reflected Resident #1 was an [AGE] year-old female with admission date of 02/26/24. Resident #1 has diagnoses including hemiplegia and hemiparesis (condition that affects movement on one side of the body), sepsis (life threating infection), and kidney failure (kidneys do not filter waste and toxins from blood). Record review of Resident #1's Quarterly…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan with measurable objectives to meet resident's highest practicable physical, mental, and psychosocial well-being for 3(Resident #1, Resident #11, and Resident #31) of 12 residents reviewed for comprehensive person-centered care plans. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of leg braces for Resident #1. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of intravenous antibiotics and infection for Resident #11. The facility failed to develop care plans based on the assessed needs with measurable objectives and timeframes in area of feeding tube for Resident #31. This failure could place the residents at risk for decreased quality of life and not having their needs met. Findings include: Resident #1 Review of Resident #1's…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and records review, the facility failed to provide the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 5 (10/19/24, 10/20/24, 11/16/24, 11/17/24, 12/27/24) of 201 days reviewed. There was no RN coverage on the following dates: 10/19/24, 10/20/24, 11/16/24, 11/17/24, 12/27/24. This failure could place residents at risk for injury, decline or death during a situation requiring the advanced knowledge and skills of an RN to intervene and supervision of the direct care staff. Findings included: Review of the Payroll Based Journal Staffing Data Report from CMS dated FY Quarter 1 (October 1 to December 31) accessed on 05/15/25 revealed the facility failed to report RN hours on 10/19/24 (SA); 10/20/24 (SU); 11/16/24 (SA); 11/17/24 (SU) and 12/27/24 (FR). During an interview on 05/21/25 at 08:49 AM, the Administrator stated there was no RN coverage on 10/19/24 and 10/20/24. He stated the weekend RN scheduled quit without notice. The Administrator stated the DON covered on 11/16/25 and 11/17/25 and there was RN coverage on 12/27/24…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview and record review, the facility failed to ensure the comprehensive assessment accurately reflected the resident's status for 2 (Resident # 1 and Resident # 11) of 12 Residents reviewed for accuracy of assessments. The facility failed to ensure MDS dated [DATE] reflected the use of a right and left leg brace for Resident #1. The facility failed to ensure MDS date 05/07/2025 reflected the use of antibiotics for Resident #11. This failure could place residents at risk of inaccurate assessments and not receiving appropriate care according to their status. Findings include: Resident #1 Review of Resident #1's electronic face sheet revealed a [AGE] year-old female who was admitted to the facility on [DATE] with diagnosis to include: diabetes, muscle wasting, and unsteadiness on feet. Review of Resident #1's MDS dated [DATE] revealed: BIMS of 10 which indicated moderate cognitive impairment. Review of Section O revealed no Splint or brace assistance. Review of Resident #1's Comprehensive…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interview and record review, the facility failed to utilize the services of a Registered Nurse for at least 8 consecutive hours a day, seven days a week for 75 of 183 days reviewed for RN Coverage. The facility failed to provide evidence a Registered Nurse (RN) worked 8 consecutive hours a day, seven days a week for 65 days out of 92 days in Fiscal Year (FY) Quarter 1 2024 (October 1 - December 31) and 10 out of 91 days from January 1, 2024 to March 31, 2024. This failure could place residents at risk for altered physical, mental, and psychological well-being due to decisions that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring the direct care staff. Findings included: Record review of the facility's Payroll Based Journal Staffing Data Report for Fiscal Year Quarter 4 (October 1 - December 31) revealed no RN coverage on October 1, 7, 8, 14, 15, 21, 22, 28, 29, 30, and 31, 2023, November 1, 3, 4, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 20, 21, 22, 23, 24, 25, 26, 27, 29 and 30, 2023, and December 2, 3,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview and record review, the facility failed to develop and implement a person-centered, comprehensive care plan for each resident, consistent with resident rights, that included measurable objectives and timeframes to meet residents medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for 5 (Resident #8, Resident #9, Resident #19, Resident #26, and Resident #31) of 5 residents reviewed for care plans. The facility failed to develop care plans based on assessed needs with measurable objectives in areas such as pain management, weight loss or gain, urinary control, psychotropic medications, difficulty sleeping, implanted pacemaker, high blood pressure medications, blood thinning medications, and seasonal allergies for Resident #8. The facility failed to develop care plans based on assessed needs with measurable objectives in areas such as infection control, behaviors, compliance with physician's orders, pain management, risk for malnutrition, mobility,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based 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 for kitchen sanitation. The facility failed to ensure foods were sealed and/or labeled properly in dry food storage and freezers. The facility failed to properly thaw frozen meats to prevent unsafe temperature. These failures could place residents that eat out of the kitchen at risk for food borne illnesses. Findings included: An observation of kitchen on 04/02/2024 between 8:31 a.m. and 8:48 a.m. revealed: Sink #1 Clear plastic bag of what appeared to be chicken thighs sitting in sink not surrounded by water. Tap water running over top and down the side of clear plastic bag. Freezer #1 Unsealed package of circular frozen meat patties sitting in box. Freezer #2 Unsealed package of circular frozen pastry that was not labeled or dated. Dry Storage Unsealed clear plastic bag or what appeared to be curly pasta. Unsealed bag labeled alfredo sauce mix. An observation of…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interviews and record reviews, the facility failed to ensure a Minimum Data Set (MDS) assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 3 residents (Resident #16) reviewed for MDS information. The facility failed to encode, complete, and submit a discharge MDS for Resident #16. This failure could place residents at risk of facilities have provided resident specific information for payment and quality measure purposes. Findings included: Closed record review of Resident #16's face sheet dated 04/03/2024 revealed a [AGE] year-old male that admitted into facility on 10/03/2023 and discharged on 10/07/2023. Closed record review of Resident #16's care plan dated 10/08/2023 revealed I will have access to necessary services to promote adjustment to my new living environment and or post discharge from facility. Closed record review of Resident #16's MDS assessment completion list did not reveal a Discharge MDS had been completed. During an…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on interview, and record review the facility failed to ensure each resident's person-centered comprehensive care plan was reviewed and revised by the interdisciplinary team after each assessment for 2 (Resident #9, and Resident #185) of 7 residents reviewed for care plans. -The facility failed to ensure Resident #9's care plan accurately addressed intravenous antibiotic therapy. -The facility failed to ensure Resident #185's care plan addressed an accurate smoking status. These failures could affect residents of the facility by not accurately addressing their physical, mental, and psychosocial needs for each to attain or maintain their highest practicable physical, mental, and psychosocial outcome. Findings included: Review of Resident #9's electronic face sheet revealed a [AGE] year-old male admitted to the facility on [DATE] with medical diagnoses of Type 2 diabetes, difficulty walking, Pseudomonas (type pf bacteria), dementia, epilepsy (seizure disorder), heart failure, respiratory disease, weakness,…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on record reviews and interviews, the facility failed to complete discharge summaries that included a recapitulation of the resident's stay including, but not limited to, diagnoses, course of illness/treatment or therapy, and pertinent lab, radiology, and consultation results for 1 of 3 residents (Resident #16) reviewed for discharge. The facility failed to provide Resident #16 with discharge summary when discharged from facility. This failure places residents at risk for incomplete and cohesive care after discharge from the facility. Findings included: Closed record review of Resident #16's face sheet dated 04/03/2024 revealed a [AGE] year-old male that admitted into facility on 10/03/2023 and discharged on 10/07/2023 with diagnoses that included: personal history of transient ischemic attack (mini stroke), cerebral infarction without residual deficits (stroke without deficits), hypertension (high blood pressure), and chronic obstructive pulmonary disease (chronic lung disease interfering with airflow).…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

Based on interviews and record reviews, the facility failed to utilize the services of a RN for 8 consecutive hours 7 days a week and did not designate a RN as a DON on a full-time basis. The facility failed to have a RN for 8 consecutive hours 7 days a week. The facility failed to designate a RN as a DON on a full-time basis. These failures placed all residents at risk for their clinical needs not being met. Findings included: During an interview on 01/23/23 at 9:15AM with the interim ADM, he said when he began working on 12/05/22, the facility did not have a DON and a DON had been hired afterwards but only worked from 01/02/23 to 01/06/23. ADM said the facility routinely did not have a RN to work weekends for a long time. He said he was aware that the facility had federal citations written for not having RN coverage over the last few years and that it ran a risk for the residents' safety by not having a RN on staff. ADM said that the Covid-19 pandemic, the traveling nurse wages, and the facility's rural location made it difficult to hire and maintain RN staff. He said the…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.

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 in the facility's only kitchen. The facility failed to appropriately label, date, seal and/or close items stored in on shelves in the food preparation area, refrigerator, freezers, and dry storage area; The facility failed to discard expired food items; The facility failed to ensure appliance interior surfaces were clean; The facility failed to ensure shelves were clean and maintained in a manner that was able to be sanitized. This deficient practice could affect residents who receive meals prepared from the kitchen by putting them at risk for food borne illness due to cross contamination. Findings included: Observations on 01/23/23 from 09:30 AM to 10:55 AM of the kitchen revealed the following items not properly labeled, dated, sealed and/or closed: A shelf in the food preparation area: One open bag of chips. No date opened or use by date. One open squeeze bottle of chocolate syrup. No date opened, use…

This is the beginning of the surveyor’s statement, cut to keep the page readable — the full 2567 continues past this point and often ends with the findings that matter most, such as whether an immediate jeopardy was removed before the surveyors left. The complete statement of deficiencies is a public record: request it from your state survey agency, or ask the home for its 2567 and plan of correction — it must make them available to residents and families.