Avir at Belton

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remained free from accident hazards and the residents received adequate supervision and assistance to prevent accidents for 1 of 5 residents (Resident #1) reviewed for accidents and failed to properly transfer residents 3 (Resident # 2, # 3, 4) of 6 residents reviewed for transfer status. The facility failed to prevent Resident #1 from falling when CNA A transferred resident alone without using a mechanical lift (specialized device designed to safely transfer individuals with limited mobility ) resulting in Resident #1's fall and sustained a fractured right ankle on 05/01/26. Resident #1 stood and pivoted to the toilet and CNA A attempted to prevent resident from falling when resident slid to floor from toilet. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident maintained acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrated this was not possible or the resident's clinical condition demonstrated that this was not possible or resident preferences indicated otherwise for 6 of 6 Residents (Residents #4, Resident # 5, Resident # 6, Resident # 7, Resident # 8 and Resident # 9) reviewed for nutrition status maintenance. [...]

Inspectors wroteBased on interview 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 residents (Resident #1, Resident #2, Resident #3 and Resident #4) 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:1. Record review of Resident #1 face sheet, dated 04/29/26, reflected a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 3 residents (Resident #2, Resident #3 and Resident #4) reviewed for quality of life. The facility failed to ensure Resident #2, Resident #3 and Resident #4 received regular showers. This failure could place residents at risk of not receiving services or care, diminished quality of life, infections, rashes, and decreased self-esteem.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide pharmaceutical services (including procedures that assured the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals) to meet the needs of each resident for 3 of 3 residents (Resident #1, Resident #2 and Resident #3) reviewed for pharmacy services. 1. The facility failed to ensure medications were administered in a timely manner to Resident #1. 2. The facility failed to ensure medications were administered in a timely manner to Resident #2. 3. The facility failed to ensure medications were administered in a timely manner to Resident #3. These deficient practices could place residents at risk for adverse effects and not receiving the therapeutic effects of the medication or treatment.

Inspectors wroteBased on interview and record review the facility failed to ensure, in accordance with accepted professional standards and practices, medical records were maintained on each resident that were complete and accurately documented for 3 of 3 residents (Resident #2, Resident #3 and Resident #4) reviewed for complete and accurate records. The facility failed to ensure RN D documented medications at the time administered to Resident #2, Resident #3, and Resident #4. This failure could place residents at risk of harm or not receiving desired outcomes from medications not administered according to physician's orders and manufacturer's specifications.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 2 of 4 medication carts (MC #1, and MC #3) reviewed for drug storage and labeling.1. The facility failed to ensure MC #1, was locked, medications secured, and not accessible to other staff, residents, or visitors.2. The facility failed to ensure MC #2, was locked, medications secured, and not accessible to other staff, residents, or visitors. These failures could place residents at risk of having unauthorized access to medications, decreased effectiveness of medication, or missing medications.

Inspectors wroteBased on interviews and observations, the facility failed to ensure 1 of 6 residents (Resident #1) received services in the facility with reasonable accommodation of resident needs and preferences. Resident #1 had to wait 30 minutes for the call light to be answered, and according to Resident #1 had not received a shower in almost 2 weeks. This failure could place residents at risk of harm and/or isolation.

Inspectors wroteBased on interviews and observations, the facility failed to ensure residents had the right to a dignified existence, self-determination, and communication for 2 of 6 (Resident #1 and Resident #2) residents reviewed for resident rights; in that:The facility failed to ensure that Resident #1 and Resident #2 received their showers as scheduled. This failure could place residents at risk for decreased quality of life, isolation, and skin breakdown. Findings Included: [...]

Inspectors wroteBased on interviews, observation and record reviews, the facility failed to develop and implement a comprehensive, person-centered care plan consistent with resident rights, including measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs, as identified in the comprehensive assessment, for 3 of 3 residents. reviewed for comprehensive care plans. The facility failed to adequately address fall/safety concerns specific for Residents #10. The facility failed to adequately address fall/safety concerns specific for Residents #12. The facility failed to adequately address fall/safety concerns specific for Residents #14. This failure could place residents of not receiving necessary care or proper care/treatment for falls.

Inspectors wroteBased on interview and record review the facility failed to establish a system of record of receipt and disposition of all controlled drugs in sufficient detail to enable an accurate reconciliation for 1 of 4 medication carts (Medication Aide Cart for 100,300,500 Halls) reviewed for medication storage and labeling. The facility failed to ensure residents were free of any significant medication errors for one (Resident #54) of five residents reviewed for significant medication errors. The facility failed to record receipt and reconciliation of medication aide cart for 100,300,500 each shift change. The facility failed to ensure Resident #54 was administered her prescribed nighttime medications within the allotted time. This failure could place residents at risk of drug diversions and could result in diminished health and well-being. [...]

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for (Resident #2) reviewed for PASRR Level I screenings. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #2. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (post-traumatic stress disorder with an onset date of 02/16/23) was present upon Resident #2's admission date on 02/16/23. This failure could place residents who had a mental illness at risk of not receiving a needed assessment (PASRR Evaluation), individualized care, or specialized services to meet their needs.

Inspectors wroteNumber of residents sampled: Number of residents cited: Based on observation, interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care for (Resident #9) reviewed for baseline care plans. The facility failed to complete a baseline care plan within 48 hours of admission for Resident #9. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interviews and record review, the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 6 residents (Resident #1) reviewed for accidents hazards and supervision, in that: The facility failed to ensure on 10/16/2025 Resident #1 was transferred by CNA A and RN A using standing pivot transfer x 2 staff without a gait belt. During transfer Resident #1 became too heavy for CNA A and RN A and Resident # 1 was lowered to the floor causing Resident # 1 knees to be in a bent position while sitting on the floor. Resident #1 was sent to the hospital and diagnosed with a displaced periprosthetic distal Femoral fracture (broken thigh bone near a hip implant that has shifted out of position) The non-compliance was identified as past noncompliance (PNC). The noncompliance began on 10/16/25 and ended on 10/27/2025. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident was treated with respect, dignity, and care in a manner and in an environment that promoted maintenance or enhancement of his or her quality of life for 1 of 7 residents (Resident #4) reviewed for Resident Rights. The facility failed to ensure Resident #4 was treated with respect, dignity, and care while CNA A was assisting her to attend to grooming and dressing for breakfast in the dining room. This failure could place residents at risk for a loss of dignity, decreased self- worth, and decreased self-esteem. The non-compliance was identified as PNC. The noncompliance began on 12/03/2024 and ended on 12/5/2024. The facility had corrected the non-compliance before the investigation began.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident had the right to be free from physical abuse for 1 of 7 residents (Resident #4) reviewed for abuse. CNA A awakened Resident #4 abruptly, was rude and rough with her. The resident stated CNA A dug the comb in her scalp while combing her hair. Resident #4 was crying, shaking, and stated she did not feel safe. The non-compliance was identified as PNC. The noncompliance began on 12/03/2024 and ended on 12/5/2024. The facility had corrected the non-compliance before the investigation began. This failure placed residents at risk of fear and physical/psychosocial injury.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure food was stored, prepared, distributed, and served in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food storage, labeling, dating, and kitchen sanitation. 1. The facility failed to ensure the tea was covered with a lid. 2. The facility failed to ensure expired foods in the facility's refrigerator and freezer were discarded according to guidelines. 3. The facility failed to ensure foods in the refrigerator and freezer were properly sealed from air-borne contaminations. 4. The facility failed to ensure hairnets were worn while in the kitchen, while breakfast was being prepared and served, in the kitchen area. 5. The facility failed to clean the food storage bins in the dry food storage area. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 5 (room [ROOM NUMBER], #2, #3, #4, and #5) of 12 resident rooms reviewed for cleanliness and sanitization. The facility failed to ensure that Resident Rooms #1, #2, #3, #4, and #5 were thoroughly cleaned and sanitized. This deficient practice could place residents at risk of living in an unclean and unsanitary environment which could lead to a decreased quality of life.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice for 7 (Resident #24, Resident #25, Resident #12, Resident #31, Resident #54, Resident #17, and Resident #16) of 10 residents reviewed for Respiratory Care. 1. The facility failed to ensure that Resident #24's nasal cannula (flexible tube used to deliver oxygen to the nose through two prongs) was properly stored. 2. The facility failed to ensure that Resident #25's nebulizer (machine that turns liquid medication into a mist and breathed directly into the lungs) face mask was properly stored. 3. The facility failed to ensure that Resident #12's CPAP (continuous positive airway pressure: machine used to deliver pressurized air through a mask to keep airways open) was stored properly. 4. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to receive services in the facility with reasonable accommodation of resident needs and preferences for 1 (Resident #12) of 10 residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #12's room was in a position that was accessible to Resident #12. This failure could place Resident#12 at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to maintain an infection control program designed to provide a sanitary environment and to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #50) of 4 residents observed for Infection Control. The facility failed to ensure that CNA B changed gloves and performed hand hygiene while providing incontinent care to Resident #50. These failures could place the residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for one of five residents (Resident #2) reviewed for dignity. The facility failed to ensure Resident #2's catheter bag was covered while he was in a communal area on 07/03/24. This failure placed residents at risk of embarrassment and diminished quality of life.

Inspectors wroteBased 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 to help prevent the development and transmission of communicable diseases and infections for one (Resident #1) of five residents reviewed for infection control practices. CNA A failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #1 on 07/03/24. This failure could place residents at risk for the spread of infection.

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, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for one (1) of four (4) residents (Resident #1) reviewed for indwelling catheter care and one (1) of seven (7) medication carts (Medication Cart #1 ) reviewed for contamination. 1. The facility failed to ensure CNA A appropriately sanitized his hands during indwelling catheter care for Resident #1. 2. The facility failed to ensure LVN B kept medication cart #1 free from contamination of exposed food and drink. These failures could result in the spread of diseases to residents which could result in decreased quality of life, illness, and hospitalization.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure a person designated as the infection preventionist worked at least part-time at the facility for one of one infection preventionist reviewed. The facility did not have an infection preventionist in place who worked at least part-time at the facility. The DON was the infection preventionist and did not work at least part-time in the position at the facility. This deficient practice could place residents at risk of cross contamination and infection.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident's medical record included documentation that indicates the resident received education on the influenza immunizations of 3 of 7 residents (Residents #1, Resident #2, and Resident #3) reviewed for immunizations. The facility failed to ensure Resident #1, Resident #2, and Resident #3 received education on the influenza immunization. This failure could place residents at risk for contracting a viral disease and cause respiratory complications and potential adverse health outcomes.

Inspectors wroteBased on interviews and record reviews, the facility failed to notify the physician and the resident's responsible party for 1 (Resident #18) of 3 residents reviewed for resident rights. The facility failed to notify Resident #18's physician and RP that the resident did not receive 12 doses of Torsemide between 08/01/23 and 08/07/23 as ordered.) This failure resulted in the identification of Immediate Jeopardy (IJ) on 08/15/23 at 3.22 PM. While the immediacy was removed on 08/18/23 at 10:50 AM, the facility remained out of compliance with a severity of no actual harm due to the facility's need to monitor the implementation of the plan of removal. This failure could place residents at risk of complications from deterioration in health, worsening of conditions, extended recoveries, and hospitalizations.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 3 residents (Resident #18) reviewed for pharmacy services. The facility failed to ensure Resident #18 received 12 doses (08/01/23 to 08/07/23) of Torsemide (for the treatment of fluid retention (edema) caused by congestive heart failure, kidney disease, or liver disease due to its unavailability in facility. This failure resulted in the identification of Immediate Jeopardy (IJ) on 08/15/23 at 3.22 PM. While the immediacy was removed on 08/18/23 at 10:50 AM, the facility remained out of compliance with a severity of no actual harm due to the facility's need to monitor the implementation of the plan of removal. [...]

Inspectors wroteBased on record review and interviews, the facility failed to meet the minimum of 14 hours between a substantial evening meal, dinner, and breakfast the following morning without providing a nourishing snack or attaining a resident group agreement to expand up to 16 hours for the meal span, for 5 of its 68 residents (Res # 18, # 35, # 62, # 52, and # 222) observed in the dining observation task. 1. The facility failed to provide a nourishing evening snack to each resident consisting of enough calories and nourishment to last from dinner, served at 4:45 PM until breakfast the next morning, at 7:45 AM; which was 15 hours. 2. The facility failed to consult with the resident population to seek input on extended times between mealtimes and the provision of a nourishing snack. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to store food in accordance with professional standards for food safety in the facility's only kitchen. The facility failed to label foods stored in the facility's pantry, refrigerator, and freezer with an open date and a date of expiration; the facility failed to keep food from being stored directly on the floor. These failures placed residents at risk for transmission of food borne pathogens.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 1 of 8 residents (Resident #32) reviewed for resident rights in that: The facility failed to ensure Resident #32's call light was within reach. This failure could affect residents who needed assistance with activities of daily living and could result in needs not being met.