Avir at Bryan

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observations, interviews and record review, the facility failed to provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs for 1 of 17 (Resident #23) residents reviewed for medication administration. The facility failed to ensure staff did not leave medication with Resident #23 when there was not a self-administer assessment completed. This failure could place residents at risk of not accurately receiving their medications, which could cause a change in condition.Findings Included: Record review of Resident #23's face sheet dated 05/14/2026 revealed a [AGE] year-old male who was admitted to the facility on [DATE]. Resident #23 had diagnoses which included seizures, difficulty in walking, anxiety (feeling of uneasiness or worry), major depressive disorder (mental health disorder characterized by persistent depressed mood), headaches, cancer, and hypertension (high blood pressure).…

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 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 1 of 1 dining rooms reviewed for infection control. The facility failed to ensure CNA D washed and sanitized her hands between passing breakfast trays to the residents. The facility failed to ensure CNA E washed and sanitized her hands between passing breakfast trays to the residents. These failures could place residents at risk for cross contamination and the spread of infection. Findings included: During an observation of dining services for breakfast meal services on 05/12/2026 at 7:44a.m., revealed CNA D and CNA E did not wash or sanitize their hands while passing meal trays to residents in the dining room. During an interview with the DON on 05/14/2026 at 10:02a.m., she said she had been trained on hand hygiene. She said the policy for hand hygiene during meal services was staff were to wash…

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 review, the facility failed to ensure prompt resolution of grievances regarding the resident's right to file a grievance for 4 of 4 confidential residents reviewed for grievances.The facility failed to notify residents in writing of the findings and actions of the grievances they filed. This failure could affect resident's right to a written decision regarding the resolution of their grievance.Findings included:Review of the March 2026 grievance log revealed 17 grievances. The column titled Disposition of Grievance* revealed the nature of the grievance for each grievance. The column titled Date of Written Decision was left blank for each grievance. The March 2026 grievance log revealed * Disposition of Grievance: Confirmed/Not Confirmed, Resolved/Not Resolved across the bottom of the log.Review of the March 2026 grievances revealed 10 of the 17 grievances did not have the section titled Findings of Investigation completed.During an interview and record review on 04/02/2026 at 01:15 PM, the ADON stated she had signed 12 of the 17 grievances for March…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biological) to meet the needs of each resident for one of four residents (Resident #1) reviewed for medications and pharmacy services.The facility failed to ensure Resident #1 had his prescribed clonidine (a medication for high blood pressure) 0.3mg/24HR transdermal (applied to the skin) patches available for administration.This failure could place residents at risk of not receiving the intended therapeutic benefits of the medication and symptomatic changes in vital signs.Findings included:Record review of Resident #1's face sheet, dated 04/01/2026, reflected a [AGE] year-old male admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: chronic kidney disease, unspecified (the gradual loss of kidney function), essential hypertension (high blood pressure), and…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drug and biologicals) to meet the needs of each resident for one of four residents (Resident #2) reviewed for medications and pharmacy services, in that: The facility failed to ensure Resident #2's physician ordered medications Bisacodyl, lactobacillus, and polyethylene glycol prescribed for his Ogilvie syndrome. These deficient practices could place residents at risk of not receiving therapeutic dosage of medications and symptomatic changes in vital signs.Findings included:Review of Resident #2's face sheet dated 03/11/2026 reflected he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Ogilvie syndrome (An intestinal pseudo-obstruction feels like something is physically blocking your bowels. But they aren't actually obstructed because they're paralyzed.),…

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 review, the facility failed to ensure residents had the right to be free from exploitation and misappropriation of property for one of four residents (Resident #1) reviewed for misappropriation of resident property. The facility failed to protect Resident #1 from CNA A, who at some point during her employment from 10/30/2025 through 12/09/2025 took Resident #1's debit card and incurred at least 36 unauthorized charges from 11/29/2025 through 02/08/2026. This failure placed residents at risk of misappropriation of property and financial loss. Findings included: Review of Resident #1's face sheet dated 11/10/2025 reflected a [AGE] year old female admitted to the facility on [DATE] with the following diagnoses: dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), Diabetes Mellitus (A condition results from insufficient production of insulin, causing high blood sugar.), and hypertension (High pressure in the arteries (vessels that…

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 residents are offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet for one of four residents (Resident #2) reviewed for physician ordered supplements. The failed to ensure Resident #2 received his physician ordered supplement ensure clear with his lunch meal. This failure placed residents at risk for weight loss, malnutrition, and poor quality of life.Findings included: Review of Resident #2's face sheet dated 03/11/2026 reflected he was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses: Ogilvie syndrome (An intestinal pseudo-obstruction feels like something is physically blocking your bowels. But they aren't actually obstructed because they're paralyzed.), hemiplegia and hemiparesis (Hemiplegia is a symptom that involves one-sided paralysis. Hemiplegia affects either the right or left side of your body.) following a cerebral…

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 parenteral fluids must be administered consistent with professional standards of practice and in accordance with physician orders, the comprehensive person-centered care plan, and the resident's goals and preferences for 1 of 6 residents (Resident #2) reviewed for parenteral fluids The facility failed to ensure Resident #2's PICC line dressing was changed per physician orders. This failure could place residents with PICC line dressing at risk for potential infections.Findings included: Review of Resident #2's face sheet dated 09/04/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Staphylococcal arthritis, left knee, (infection of knee joint) sepsis (occurs when your immune system has a dangerous reaction to an infection) and methicillin susceptible staphylococcus aureus infection. Review of Resident #2's admission MDS dated [DATE] reflected she was assessed to have a BIMS score…

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 must provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 1 of 4 medication carts reviewed (station 1 medication cart). The facility failed to ensure on 09/04/2025 that expired medications (one bottle of Melatonin 1mg expired 08/2025 and one bottle of Aspirin 325 mg expired 08/2025) were removed from the station one medication cart once expired. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications.Findings Included: Observation on 09/04/2025 at 2:30 pm of station one medication cart revealed a bottle of Melatonin 1mg expired 08/2025 and one bottle of Aspirin 325 mg expired 08/2025. In an interview on 09/04/2025 at 2:35 pm, LVN A stated it was the medication aide's responsibility to ensure expired medication are not on the cart, but they currently did not have one and since he was passing…

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 ensure storage of drugs and biologicals used in the facility for 1 of 4 medication carts reviewed (station 1 medication cart). The facility failed to ensure medications were stored and used in an orderly manner to ensure the liquid did not run down the sides of the bottle causing it to be sticky on the sides of the bottle and the bottle was stuck to the bottom of the medication cart drawer. This failure could place residents who received medications at risk of not receiving the intended therapeutic effect of the medications. Findings Included: Observation on 09/04/2025 at 2:30 pm of station one medication cart revealed a bottle of lactulose in the medication cart drawer which was sticky on the sides of the bottle and the bottle was stuck to bottom of cart. In an interview on 09/04/2025 at 2:35 pm, LVN A stated the lactulose bottle was sticky and should have been cleaned. In an interview on 09/04/2025 at 3:00 PM the DON stated that staff should check the medication prior to administration to ensure 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on 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 1 of 6 (Resident #1) residents reviewed for infection control practices. The facility failed to ensure LVN A followed standard precautions during wound care on 09/04/2025 for Resident #1's RLE stasis ulcer, when he failed to perform hand hygiene prior to wound care, and between glove changes and failed to use gloves that were not contaminated. This failure could place residents at risk for developing wound infections and risk for healthcare associated cross-contamination and infections.Findings included: Review of Resident #1's face sheet dated 09/04/2025 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: alcohol dependence, major depression and muscle wasting.…

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 ensure nurse staffing information was posted to include: facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift for, registered nurses, licensed practical nurses or licensed vocational nurses, certified nurse aides, and resident census for 1 of 1 day (07/09/25) reviewed for posted nurse staffing information. The facility failed to have daily nurse staffing posted on 07/09/25. This failure could place residents at risk of not knowing how many nursing staff should be present in the facility. Based on observation, interview and record review the facility failed to ensure nurse staffing information was posted to include: facility name, the current date, the total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift for, registered nurses, licensed practical nurses or licensed…

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 provide pharmaceutical services (including procedures that assure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for one (Resident #1) of three residents reviewed for pharmacy services. The facility failed to prevent a diversion of Resident #1's Modafinil 100 MG tablet, 30 tablets received from the pharmacy on 06/15/2025 and reported missing on 06/16/2025. LVN A and LVN B failed to conduct shift change narcotics medication count on the morning of 06/16/2025. These failures could place residents at risk for medication error and delay therapy. Findings include: Record review of Resident #1's face sheet, printed 06/26/2025, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. Her diagnoses included sleep apnea (a common sleep disorder where breathing repeatedly stops and starts during sleep), unspecified, obstructive sleep apnea (a common sleep…

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 review, the facility failed to maintain medical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 of 14 residents (Resident #1, Resident #2, and Resident #3) reviewed for medication administration, treatment administration, and wound administration. 1. The facility failed to complete Resident #1's Medication Administration Record (MAR), Treatment Administration Record (TAR), Wound Administration Record (WAR), and Controlled Drug Record for Norco 5-325 MG, Norco 10-325 MG, Pregabalin, tramadol PRN, tramadol three times a day and wound cleanse treatments. 2. The facility failed to accurately document Resident #1's Medication Administration Record (MAR), Treatment Administration Record (TAR), Wound Administration Record (WAR), and Controlled Drug Record for Norco 5-325 MG, Norco 10-325 MG, Pregabalin, tramadol PRN, tramadol three times a day and wound cleanse treatments. 3. The facility failed to…

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 observations, interviews, and record review, the facility failed to implement a comprehensive care plan to meet the resident's highest practicable physical, mental, and psychosocial well-being of 3 (Resident #13, Resident #53, and Resident #212) of 12 residents reviewed for care plans. The facility failed to develop and implement the comprehensive person-centered care plan for Resident #13's refusal to be weighted monthly. The facility failed to develop and implement the comprehensive person-centered care plan for Resident #53's refusal to sit up out of bed at a 90-degree angle during all meals. The facility failed to develop and implement the comprehensive person-centered care plan for Resident #212's use of a CPAP machine. These failures could place residents at risk for not receiving appropriate care and treatment. Findings included: Record review of Resident #13's Face Sheet reflected an [AGE] year-old female who was admitted on [DATE] with a diagnosis of Nontoxic Multinodular Goiter (an enlarged…

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 residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for three (Resident #5, Resident #209, Resident #212) of five residents reviewed for bathing. The facility failed to provide showers to Resident #5, Resident #209, Resident #212 in compliance with their shower schedules. This deficient practice could place residents at risk of a decline in their sense of well-being, level of satisfaction with life, and at risk for skin breakdown. Findings included: Review of Resident #5's comprehensive MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction high blood pressure, stroke, high blood lipids, seizure disorder, depression, partial weakness on one side of the body, dysphagia, abnormal posture, muscle weakness. Resident #5 had a BIMS score of 08, which indicated moderately…

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 store, prepare, distribute, and serve food in accordance with professional standards for food service safety for the facility's nourishment refrigerators for 3 (Nourishment room [ROOM NUMBER], #3, and #4) of 5 nourishment room refrigerators reviewed for food and nutrition services. 1. The facility failed to ensure the nourishment room refrigerator temperature logs were maintained in dining room [ROOM NUMBER], and nourishment refrigerators #3 and #4. 2. The facility failed to ensure the dining room's refrigerator's cleanliness was maintained. 3. The facility failed to ensure the nourishment refrigerator in unit 1 was free of pests. These failures could place residents at risk for health complications, foodborne illnesses and decreased a quality of life. Findings include: Observation of the unit 3 and 4 dining room's refrigerator on 3/25/2025 at 12:18 PM revealed a lone sign posted to the front of the refrigerator notifying residents,…

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 complete a comprehensive assessment within 14 calendar days after admission as required for 2 (Resident #209 and Resident #212) of 5 residents records reviewed for comprehensive assessment accuracy and timing. Resident #209 and Resident #212 did not have completed admission/comprehensive MDS assessments within 14 days following their admissions to the facility. This deficient practice could result in newly admitted residents not receiving the proper care required to attain or maintain the highest practicable physical, mental, and psychosocial well-being. Findings included: Review of Resident #209's undated face sheet reflected a [AGE] year-old male who was admitted to the facility on [DATE] and had the following diagnoses: acute kidney failure, altered mental status, primary osteoarthritis of knee (degenerative joint disease that results from breakdown of joint cartilage and underlying bones), low potassium, hyperosmolality (loss of water fluid).…

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 a resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living for 1 of 27 residents (Resident #18) reviewed for ADL activities The facility failed to ensure Resident #18 was monitored for assistance needs and failed to ensure she was positioned in a manner that would allow her to feed herself while in bed. This failure could place residents at risk for weight loss, ADL decline and poor self-esteem. Findings included: Review of Resident #18's face sheet dated 03/26/2025 reflected a [AGE] year-old female admitted on [DATE] with the following diagnoses dementia (A group of symptoms that affects memory, thinking and interferes with daily life.), chronic obstructive pulmonary disease (Is a common, preventable, and treatable disease that is characterized by persistent respiratory symptoms like progressive breathlessness and cough.) and anorexia (an eating…

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 provide treatment and care in accordance with professional standards of practice for 1 (Resident #5) of 5 residents reviewed for quality of care. The facility failed to ensure MA F waited for Resident #5 to consume her nighttime medications before leaving the resident's room. This failure could affect residents by putting them at risk of not receiving the therapeutic benefits of their medications. Findings included: Review of Resident #5's comprehensive MDS, dated [DATE], reflected a [AGE] year-old female who was admitted to the facility on [DATE] with diagnoses including non-traumatic brain dysfunction, high blood pressure, stroke, high blood lipids, seizure disorder, depression, partial weakness on one side of the body, dysphagia (difficulty swallowing), abnormal posture, and muscle weakness. Resident #5 had a BIMS score of 08, which indicated moderately impaired cognition. The assessment stated none of the above under swallowing…

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 a resident who needed respiratory care, was provided such care, consistent with professional standards of practice for one (Resident #212) of 5 residents reviewed for respiratory care. The facility failed to have a physician's order and a plan of care for the use of a CPAP machine and a nebulizer for Resident #212 This failure could place residents at risk of receiving incorrect or inadequate treatment and could result in a health decline or infection. Findings included: Record review of Resident #212's undated face sheet reflected an [AGE] year-old male who was admitted to the facility on [DATE] and had the following diagnoses: unspecified dementia, diabetes, sleep apnea (breathing disorder caused by repeated interruptions during sleep), high blood pressure, atrial fibrillation (irregular heart rhythm), congestive heart failure, and gastro-esophageal reflux disease. Record review of Resident #212's care plan initiated 3/04/2025…

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 provide pharmaceutical services including procedures that assure the accurate acquiring, receiving, and dispensing of routine drugs and biologicals to meet the needs of each resident for 1of 4 resident reviewed for pharmacy services. (Resident #213) The facility failed to ensure Resident #213 ordered Thiamine (a B1 vitamin) and Ergocalciferol (a prescription strength vitamin D) medication was available for administration on 03/26/25. These failures could place residents at risk for not receiving medications as prescribed and a decline in health status Findings included: Record review of Resident #213's face sheet reflected he was admitted to the facility on [DATE] with diagnoses of Sepsis (a blood infection), Anxiety, Myasthenia Gravis (a chronic autoimmune disorder that affects the neuromuscular junction, the point where nerves meet the muscle) and mild protein calorie malnutrition. Record review of Resident #213's comprehensive care plan…

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 that the medication error rate was not five percent or greater. The facility had a medication error rate of 7.69% based on 2 out of 26 opportunities, which involved 1 of 4 residents (Resident #213) observed during medication administration reviewed for medication error. The facility failed to ensure Resident #213's ordered Thiamine (a B1 vitamin) and Ergocalciferol (a prescription strength vitamin D) medication was available for administration on 03/26/25. These failures could place residents at risk of not receiving medications as ordered Findings included: Record review of Resident #213s face sheet reflected he was admitted to the facility on [DATE] with diagnoses of Sepsis (a blood infection), Anxiety, Myasthenia Gravis (a chronic autoimmune disorder that affects the neuromuscular junction, the point where nerves meet the muscle) and mild protein calorie malnutrition. Record review of Resident #213s comprehensive care plan dated…

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 medications and biologicals were stored in locked compartments for 1 of 1 medication carts reviewed for medication storage. The facility failed to ensure the medication cart was locked and medications were secure and not accessible to other staff, resident, or visitors while unattended by MA E on 3/26/25 at 10:30am. This failure could have resulted in harm due to unauthorized access to medications, biologicals, and needles. Findings included: Observation on 03/26/2025 at 10:30am MA E left the medication cart unlocked outside of room [ROOM NUMBER] in the hallway over the counter medication Oscal (a calcium supplement) and Vitamin D supplement were left out on top of cart while she administered medications inside of the room. In an interview on 3/26/25 at 10:50am MA E stated she had worked at the facility x 1 year. She stated she has received training related for medication administration from her ADON and DON. She stated 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.

NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY Based on observation, interview, and record review, the facility failed to 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 of two medication aides (MA E) observed for infection control practices MA E failed to sanitize her hand, put on gloves prior to administration of eye drops to Resident #213 on 03/26/25 at 10:30am. This failure could place residents at risk for healthcare associated cross-contamination and infections. Findings included: Record review of Resident #213's face sheet reflected he was admitted to the facility on [DATE] with diagnoses of Sepsis (a blood infection), Anxiety, Myasthenia Gravis (a chronic autoimmune disorder that affects the neuromuscular junction, the point where nerves meet the muscle) and Glaucoma (an increased pressure inside the eye). Record review of Resident #213's history and physical dated 03/21/25…

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 use appropriate alternatives prior to installing a side or bed rails, assess the resident for risk of entrapment, review the risk and benefits, and obtain informed consent prior to installation for 3 out of 6 residents (Residents #1, #2, and #3) reviewed for bedrails. The facility failed to assess and get signed consents for Residents #1, #2, and #3 prior to installing bed rails. This deficient practice could affect residents who utilized bed rails by placing them at risk for unintended entrapment of the head, neck, or limbs, restraints, and injuries. The findings included: Record review of Resident #1's face sheet dated 08/28/24 reflected a [AGE] year-old female who admitted to the facility on [DATE] with a diagnosis of polyosteoarthritis (is a diagnosis of having arthritis in five or more joints at the same time), muscle weakness, difficulty in walking, altered mental status and cognitive communication deficit. Record review of Resident…

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 honor the residents right to choose his or her attending physician for 5 of 5 residents (Resident #1, Resident #2, Resident #3, Resident #4, and Resident #5) and the entire facility reviewed for resident rights. The facility did not honor Resident #1, #2, #3, #4, and #5's right to choose his/her primary care physician after the facility terminated their Medical Director's agreement and changed the attending physician without notice to the residents or their representatives effective 07/04/24. This deficient practice could place residents at risk of decreased quality of care and treatment due to their lack of free choice for their attending physician care while in the facility. Findings included: Resident #1 Review of Resident #1's Face Sheet dated 07/30/2024 reflected a [AGE] year-old female admitted to the facility on [DATE] with the following diagnoses: Parkinson's Disease (brain disorder that causes unintended or uncontrollable…

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 observations, interviews, and record review, the facility failed to store all drugs and biologicals in locked compartments under proper temperature controls for 1 of 3 (Resident #1) residents reviewed for pharmacy services. 1. The facility failed to ensure Resident #1's medications (1 box of 20, 600mg Mucinex tablets and 1 single 10mg Baclofen tablet) were stored and locked in an area not accessible to other staff, residents, or visitors. 2. The facility failed to dispose of medication properly- 1 loose pill (Docusate sodium 50 mg tablet) was found in the private dining room trash can. These failures could place residents at risk of injury and result in residents not receiving doses of medication as well as not being maintained at their best therapeutic level. Findings included: Record review of Resident #1's face sheet dated 06/24/24 revealed an [AGE] year-old female admitted to the facility on [DATE] with a diagnosis of multiple sclerosis (a disease where the immune system attacks the protective layer…

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 review, the facility failed to report incidents of injury of unknown sources to HHSC's state office within 24 hours for 1 (Resident #1) of 3 residents reviewed for unwitnessed falls. The facility failed to report allegations to the State Agency when Resident #1 had an unwitnessed fall and was sent out to a local hospital. This failure placed residents at risk of further injuries not being reported timely for a thorough prompt investigation to be conducted immediately. Findings Included: Review of Resident #1's face sheet dated 05/16/2024 reflected a [AGE] year-old male who was admitted to the facility on [DATE] with diagnoses including displaced intertrochanteric fracture of left femur subsequent encounter for closed fracture with routine healing(broken hip), dementia in other diseases classified elsewhere(memory loss), and hypertension(high blood pressure). Review of Resident #1's care plan was not available as the incident occurred less than 48 hours after admission. Review 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 observation, interview, and record review the facility failed to ensure that the residents environment remained as free of accident hazards as was possible in 14 of 50 resident room sinks (room [ROOM NUMBER], 226, 230, 303, 307, 310, 313, 317 319, 320, 325 329, 335, and 342) and 2 of 2 common shower areas (2nd and 3rd floor) reviewed for hot water. The facility failed to maintain resident use hot water at safe and comfortable temperatures. Resident use hot water was not reliably controlled and ranged from between 118.4 F and 129.4 in reviewed locations. This failure could place residents at risk for sustaining scalding injuries when using resident-use / resident accessible hot water. Findings included: Observation on 02/07/2024 at 8:16 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 122 F. Observation on 02/07/2024 at 8:46 AM, the hot water from the sink in room [ROOM NUMBER] was checked with a digital thermometer and found to be 123.1 F.…

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 a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for two of four residents reviewed for catheter care (Resident #46 and Resident #48). A) The facility failed to ensure Resident #46's catheter was secured to his body with a catheter secure device per the care plan and physician's orders. B) The facility failed to ensure Resident 48's catheter was secured to his body with a catheter secure device per the physician's orders and facility policy. This failure to secure catheters placed residents with urinary catheters at risk for traumatic removal and catheter acquired infections. Findings included: A) Review of Resident #46's Face Sheet dated 02/07/2024 reflected an [AGE] year-old male admitted to the facility on [DATE] with the following diagnoses: Alzheimer's Disease (A type of brain disorder that causes problems with memory, thinking and behavior. This is a…

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 that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice for 1 (Resident #18) of 4 residents reviewed for respiratory care. The facility failed to ensure that Resident #18's Nebulizer tubing and mouthpiece, which includes the nebulizing chamber (unit into which liquid medicine is converted into aerosol or mist by the pressurized air pumped through the tubing), were dated and replaced every seven (7) days. The facility failed to ensure that Resident #18's Nebulizer mouthpiece was bagged when not in use. These failures could place residents at risk for respiratory compromise and infection. Findings included: Review of Resident #18's Face Sheet dated 02/06/2024 reflected an [AGE] year-old female admitted to the facility on [DATE] with the following diagnosis: Severe Dementia (impaired ability to remember, think, or make decisions that interferes with doing everyday…

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.