Avir at Beeville

Inspectors wroteBased on interviews and record review, the facility failed to ensure that one of five residents (Resident #1) and RP was notified of the transfer or discharge and the reasons for the move in writing as soon as practicable before transfer or discharge. The facility failed to provide written notice of discharge to Resident #1 and his RP before he was discharged from the facility on 03/25/26. This failure could put residents at risk for inappropriate discharge from the facility.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to be free from abuse for 4 of 5 residents (Residents #1, #2, #3, and #4) reviewed for abuse, neglect, and exploitation. 1. The facility failed to protect Resident #2 from physical abuse when Resident #1 hit Resident #2 on the arm and kicked him in the leg on 10/15/2025. 2. The facility failed to protect Resident #1 from physical abuse when Resident #2 hit Resident #1 in the face for hitting him on the arm on 10/15/2025. 3. The facility failed to protect R #4 on 11/24/25 from being hit by R #3 in the hall of the women's locked unit. These failures could place residents at risk for physical or psychological harm or injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program, including hand hygiene, 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 #2) of fifteen residents reviewed for infection control practices, in that: The facility failed to ensure the WCN performed hand hygiene for at least 20 seconds prior and after performing Resident #2's wound care. This failure could place residents that require wound care at risk for healthcare associated cross-contamination and infections.

Inspectors wroteBased 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, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 of 1 Residents (Resident #1) reviewed for infection control and transmission-based precautions policies and practices. 1. CNA A failed to don the appropriate PPE before she entered Resident #1's room. This failure could place residents at risk for infection through cross-contamination of pathogens and infectious diseases.

Inspectors wroteBased 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 1 of (Resident #1) of 5 residents reviewed for pharmacy services. The facility failed to administer from 1/03/2025-01/06/2025 Resident #1's anticoagulant medication Eliquis 5MG BID. LVN A and RN A did not administer Resident #1's anticoagulation medication from 01/03/2025-01/06/2025 as prescribed. This failure could place residents at risk for serious complications such as atrial fibrillation, blood clots, and/or stoke.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receiving enteral feeding received appropriate care and services to prevent complication of enteral feeding for 1 of 1 resident (Resident #34) reviewed for enteral feeding. The facility failed to ensure LVN A verified placement and checked residual (something left behind) of Resident #34's G-tube (a tube into the stomach that delivers formula for nutrition and medication) by checking for tube placement and residual before enteral administration of water and medications. These failures could place residents receiving medications at increased risk of serious complications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who needs respiratory care was provided such care consistent with professional standards of practice for 1 of 16 (Resident #34) residents reviewed for oxygen in that: Resident #34's oxygen tubing was not connected to the concentrator. This failure could place residents who receive oxygen at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 8% based on 2 errors out of 25 opportunities, which involved 1 of 4 residents (Resident #34) reviewed for medication errors. Resident #34's Acetaminophen-Codeine Oral Tablet was prescribed for pain and Memantine tablet was prescribed for Alzheimers were administered by Gastrostomy tube (G-Tube), and the medication cups used contained residual medication after the medications were administered. These failures could place residents at risk of not receiving the desired therapeutic effect of their medications to manage their medical conditions and decline in health.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety for 2 of 2 unit refrigerators (unit 1 and unit 2) reviewed for sanitation. The facility failed to ensure unit refrigerators were free of unlabeled and undated items. This failure could place residents at risk for foodborne illess due to cross contamination from unlabeled and undated items in the unit refrigerators.

Inspectors wroteBased 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 three (Resident #19 and Resident #34, and Resident #218) of five residents observed for infection control. 1. LVN A did not remove his gloves after insulin medication preparation for Resident #19 and administered insulin medication with the same pair of gloves. 2. The facility failed to ensure LVN A washed his hands or used hand sanitizer between glove changes while performing medication administration for Resident #34. 3. LVN F failed to wash her hands for 20 seconds or greater after performing wound care on Resident #218. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from sexual abuse for 2 residents (Residents #2, and Resident #3) of 3 reviewed for abuse and neglect in that: The facility failed to supervise and protect Resident #2, who had a BIMS score of 3 (severe cognitive impairment), from harm and sexual abuse when Resident #2's family member provided video footage of Resident #3 grabbing Resident #2's breast on 11/7/23 and failed to protect vulnerable residents from harm and sexual abuse. An IJ was identified on 6/13/24. The IJ template was provided to the facility Administrator on 6/13/24 at 2:52pm. [...]

Inspectors wroteEvidence for tag placed under [NAME], [NAME] 609 - Reporting of Alleged Violations - E Based on, interview and record review, the facility failed to ensure that all alleged violations involving abuse, were reported immediately, but not later than 2 hours to the State Survey Agency and other officials, for 4 residents (Resident #2, Resident #3, Resident #5, and Resident #1) of 6 residents reviewed for abuse, in that: 1. The facility did not report to the Health and Human Services Commission (HHSC)/State Survey Agency and other officials for one incident of possible sexual abuse for Resident #2 and Resident #3 on 11/08/23. 2. The facility did not report to the Health and Human Services Commission (HHSC)/State Survey Agency and other officials for one incident of an unwitnessed fall resulting in an elbow fracture for Resident #5. 4. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that includes measurable objectives and time frames to meet a resident's medical and nursing needs to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 16 residents (Resident #29, Resident #17, Resident #16) reviewed for care plans in that: The facility failed to develop a comprehensive person-centered care plan for Resident #17, use of anticoagulant medication. The facility failed to develop a comprehensive person-centered care plan for Resident #29 placement in the memory unit. The facility failed to develop a comprehensive person-centered care plan for Resident #16 for a left femur fracture sustained on 3/8/2023. [...]