Avir at Abilene

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment for 4 of 6 residents (Resident #1, Resident #2, Resident #4, Resident #6) reviewed for care plans. The facility failed to ensure the comprehensive care plans for Resident #1, Resident #2, Resident #4, Resident #6 described the resident's goals for admission and desired outcomes. The facility failed to ensure the comprehensive care plan for Resident #1, Resident #2, Resident #4, Resident #6 described the resident's preference and potential for future discharge. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the residents were able to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area for 3 of 6 residents (Resident #1, Resident #3, Resident #4) reviewed for physical environment. The facility failed to ensure the volume on the call light system monitor at the nurse's station was not turned down, resulting in nursing staff not being able to hear if a resident activated their call light. This failure could place the residents at risk of inadequate care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for residents, staff and the public for 1 of 1 facility reviewed for physical environment. The facility failed to provide a sanitary and comfortable environment with clean floors for residents, staff, and the public. This failure could create a potential risk for residents' safety and comfortability.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the resident's goals and preferences for 2 (Resident #3, Resident #4) of 6 residents reviewed for quality of care. The facility failed to follow standard practices of care in keeping the intake and filter clean on the oxygen concentrator for Resident #3 and Resident #4. The facility failed to keep the intake clean in the oxygen concentrators for Resident #3 and Resident #4. This failure could place the residents at potential risk of inadequate respiratory care.

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 service safety, for 1 of 1 kitchen as evidence by: The facility failed to ensure:The low-temperature dishwasher failed to reach the required hot water minimum temperature of 120 degrees in the kitchen. This failure placed the residents at risk for foodborne illness from dishes not being sterilized properly.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for 3 of 5 residents (Resident #1, Resident #58 and Resident # 97) reviewed for comprehensive care plans.he facility failed to ensure the comprehensive care plan addressed:- Resident #1's wound on the right side of his neck. -Resident #58's plan for discharge. -Resident #97's care and maintenance of his double lumen PICC line (a line used to administer medications through a vein). These deficient practices could result in residents not receiving needed care to maintain optimum health and placing them at risk for infection and/or deterioration in their condition.

Inspectors wroteBased on interview, and record review, the facility failed to ensure the resident environment remained as free of accident and hazards as was possible and each resident receive adequate supervision and assistance devices to prevent accidents for 1 of 14 resident rooms reviewed for accident and hazards. The facility failed to ensure:The cover of an air conditioning unit was off on the ground in a 1 of 1 resident's room exposing the insides to the machine.

Inspectors wroteBased on interviews, observations, 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 5 residents (Resident #97) reviewed forIV therapy. The facility failed to obtain physician orders for the use and maintenance of Resident #97's PICC line. This deficient practice could result in residents not receiving needed care to maintain optimum health and placing them at risk for infection and/or deterioration in their condition.

Inspectors wroteBased on interview, and record review the facility failed to properly execute the grievance process including review in morning meeting with IDT members, coordinating and developing a plan for resolution, notify complainant about resolution and document all action taken in grievance form and disposition of the grievance will be provided in writing to Executive Director or Designee for 1 out of 5 resident (Resident # 1) review for grievances. The facility failed to investigate Resident #1's grievance of an incident with CNA A yelling and being rude to Resident #1. The facility failed to document all actions taken for the resolution of grievance to include Administrator's investigation. This failure could place residents in the facility at risk for grievances to go unresolved. [...]

Inspectors wroteBased on interviews and record review the facility failed to ensure residents were free from neglect for 1 of 7 (Resident $1) reviewed for neglect in that: The facility staff neglected Resident #1 when staff identified Resident #1 as having a cut to the right side of his head after an unwitnessed fall on [DATE], and did not communicate with the nurse to assess resident and begin doing neurological assessments a subdural hematoma (brain bleed) and death on [DATE]. An Immediate Jeopardy (IJ) situation was identified on 8.28.25. The IJ template was provided to the facility on 8.28.25 at 3:05 pm. While the IJ was removed on 8.29.25, the facility remained out of compliance at a severity level of no actual harm with a potential for more than minimal harm, with a scope of isolated, due to the facility's need to evaluate the effectiveness of their corrective actions. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide treatment and care in accordance with professional standards of practice for 1 of 7 (Resident #1) residents reviewed for quality of care in that: The facility staff failed to assess and monitor Resident #1, when Resident #1 was identified [DATE] as having a cut to the right side of his head, after an unwitnessed fall, which resulted in the resident being sent to the emergency room and diagnosed with a subdural hematoma (brain bleed) and death on [DATE]. An Immediate Jeopardy (IJ) situation was identified on 8.28.25. The IJ template was provided to the facility on 8.28.25 at 3:05 pm. [...]

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. The facility failed to ensure food stored in the kitchen were sealed and/or labeled properly in the facilities refrigerator #1 and freezers (#1, #2, and #4). These failures could place residents that eat out of the kitchen at risk for contamination and food borne illnesses.

Inspectors wroteBased on interview and record review, the facility failed to promote and facilitate resident self-determination through support of resident choice, including but not limited to the right to make choices about aspects of his or her life in the facility that are significant to the resident, for 3 of 3 Rresidents (Resident #97, Resident #78, and Resident #304) who was reviewed for resident rights. The facility failed to inform Resident #97 of smoking policies, resulting in resident having her cigarettes taken away and restrictions added to her smoking times. The facility failed to inform Resident #78 of smoking policies, resulting in restrictions added to his smoking times. The facility failed to allow Resident #304 to sit outside on the patio due to other residents not following the facility's smoking policy. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure an admission policy was implemented for 3 of 3 residents (Resident #97, Resident #78, and Resident #304), reviewed for admissions. The facility failed to ensure that Resident #97 reviewed and signed her admission paperwork per facility policy. The facility failed to ensure that Resident #78 reviewed and signed her admission paperwork per facility policy. The facility failed to ensure that Resident #304 reviewed and signed her admission paperwork per facility policy. These failures could place residents at risk who are not being informed of the admission requirements, services, and processes. Findings Include: Resident #97 Review of Resident #97's electronic face sheet revealed a [AGE] year-old female admitted to the facility on [DATE] with diagnosis to include: artificial hip joint, high cholesterol, and tobacco use. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 3 of 3 residents (Resident #97, Resident #78, and Resident #74) reviewed for accident hazards. The facility failed to follow the smoking policy with Resident #97 leaving her unsupervised while smoking, smoking at undesignated smoking times, and allowing her to have her cigarettes and lighter with her. The facility failed to follow the smoking policy with Resident #78 leaving him unsupervised when smoking and smoking at undesignated times. The facility failed to follow the smoking policy with Resident #74 leaving him smoking already smoked cigarettes, smoking unsupervised, and smoking at undesignated times. These failures could place residents at risk for injuries and fire hazards.

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan based on assessed needs with measurable objectives that can be evaluated or quantified to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 4 (Resident #1, Resident #2, Resident #3, and Resident #4) of 5 residents reviewed for generic comprehensive person-centered care plans. The facility failed to update care plans with personalized interventions for Resident #1, Resident #2, and Resident #4 in areas such as fall prevention. The facility failed to implement care plan interventions for Resident #3 in areas such as fall prevention. These failures could affect the residents by placing them at risk for not receiving care and services to meet their individual needs.

Inspectors wroteBased on interviews and record review the facility failed to allow residents to obtain a copy of their records or any portions thereof upon request and 2 working days advance notice to the RP for 1 of 5 (Resident #4) residents reviewed for the right to access copies of records. The facility failed to provide medical records for Resident #4 to her RP within two working days of a request on 10/29/2024. This failure could place residents and their representatives at risk by not having information about resident's care that was provided under the care of the nursing facility.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident received proper treatment and care to maintain mobility and good foot health, and provide foot care and treatment, in accordance with professional standards of practice, including to prevent complications from the resident's medical condition(s) and assist the resident in making appointments with a qualified person for 1 of 5 residents (Resident #4) reviewed for quality of care. Resident #4 did not see a podiatrist despite having thickened and long toenails and the request of the resident's RP. This failure could place residents at risk of pain, toenail injury, difficulty wearing socks and or shoes, and could result in embarrassment, frustration, anxiety, and a decreased quality of life.

Inspectors wroteBased on interview and record review the facility failed to ensure residents/resident's representative had the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options and to choose the alternative or option he or she preferred for 1 of 1 resident (Resident #1) reviewed for resident rights. Resident #1 had no consents for the antianxiety medication, Clonazepam, Ativan, Divalproex and Temazepam. Resident #1 had no consents for the antipsychotic medication Risperidone, Aripiprazole, and Haloperidol. These failures could place the resident, who received care at the facility, at risk of not being informed of their health status, to make informed decisions regarding their care.

Inspectors wroteBased on interviews and record reviews, the facility failed to implement written policies and procedures that prohibit and prevent abuse, neglect, exploitation of residents and misappropriation of resident property for 1 of 8 (CNA-A) employees reviewed for employability. Facility staff did not have criminal history check and/or an EMR/NAR check prior to offering employment to the facility and/or annually for employees. These findings placed residents at risk of receiving care by someone that was unemployable.

Inspectors wroteBased on interview and record review, the facility failed to ensure that all allegations involving abuse, neglect, exploitation or mistreatment were reported immediately but not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 (Resident #1) of 1 resident reviewed for abuse or neglect. The facility failed to report to the State Survey Agency allegations of Abuse and Neglect when learning of a positive hospital lab result for Cannabis for Resident #1. [...]

Inspectors wroteBased on record reviews and interviews, the facility failed to thoroughly investigate allegations of Abuse and Neglect for 1 of 1 resident (Resident #1) reviewed. The facility did not have documentation that a thorough investigation of allegations of Abuse or Neglect for Resident #1 who had a positive urine drug screen for Cannabinoids (also known as marijuana). This failure could place residents who report allegations of abuse/Neglect at risk of not being thoroughly investigated.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store medications used in the facility in the original containers or packaging and labeled in accordance with currently accepted professional principles for 1 of 2 (Medication Cart #1) medication carts reviewed for medication storage. The facility failed to keep each resident's medications in their original containers or packaging by placing medications in clear plastic cups then placing the cups in a medication drawer. This failure could result in drug diversion and accidental medication administration to the wrong resident.

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 service safety for 1 of 1 kitchen reviewed, in that: The facility failed to ensure open items in the freezer, refrigerator, and dry food storage were dated and labeled and free from expired foods. These failures could place residents at risk for food borne illness and cross-contamination.

Inspectors wroteBased on observation, interview and record review the facility failed to adequately provide a communication system that would relay a call directly to staff or a centralized staff work are for 2(Resident #2 and Resident #59) of 3 residents reviewed for resident call system. The facility failed to provide a working communication system, that was easily at reach, that would allow residents the ability to safely call for staff for assistance. This failure could place residents at risk of not having a means of directly contacting caregivers in an emergency or when they need support for daily living.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents were provided respiratory care received care consistent with professional standards of practice for 2 of 2 residents (Resident #11 and Resident #42) reviewed for oxygen administration. The facility failed to provide Oxygen (O2) in use sign on resident doorways for Resident #15 and #17. The facility failed to obtain a physician's order prior to administering oxygen for Resident #15. The facility failed to change the oxygen tubing every 7 days for Resident #15 and # 17. These failures could place residents who use O2 at risk for respiratory illnesses and at risk of injury from fire.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was prepared in a form designed to meet individual needs for 1 of 1 lunch meal reviewed. The facility failed to ensure the recipe was followed for pureed meatloaf. This failure placed residents who received pureed diets at-risk of inadequate nutrition and weight loss.

Inspectors wroteBased on interviews and record reviews, the facility failed to make sure that the comprehensive care plan is prepared by a team that included the attending physician, a nurse, and a nurse aide with responsibility for the resident for 6 of 6 residents (Residents #15, #48, #54, #71, #81 and #98) reviewed for care plans. The facility failed to ensure the attending physicians, nurses, and nurse aides with responsibility for the residents were invited and attended the resident care plan conferences. These failures could place the residents at risk for not receiving the care and services to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the food is at a safe and appetizing temperature for 6 residents. 1. The holding temperature for pork riblets were at 115 degrees Fahrenheit. Pork riblets require a holding temperature of 155 degrees Fahrenheit. This placed residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 6 residents (Resident #5) reviewed for accommodation of needs, received timely care assistance. The facility failed to ensure Resident #5 could make her needs known, due to the call light being out of her reach and her inability to use the call light, without assistance. This deficient practice put Resident #5 at risk due to inability to obtain assistance.

Inspectors wroteBased on interview, and record review, the facility failed to provide a safe and functional environment for residents, staff, and the public. The phone system was down for 1 of facility reviewed for safe and functional environment. 1. The facility could not make phone calls or receive phone calls or faxes from Physicians, family members, or the public. This put the residents at risk for physical, mental, and psychosocial harm.