Avir at Burkburnett

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:A. Kitchen Aide F wore a hair restraint for his moustache and goatee/beard. B. The shelves throughout the kitchen were clean and not soiled. C. The stove and oven were clean and not soiled with working knobs and all parts working. D. The grease fryer was clean and not soiled with grease buildup. E. The vent hood was clean and free of dust. F. The food cart that drinks were being prepared on was clean and not soiled. G. The food disposal was free of food. H. The food thicker was in a sealed container. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #33 and Resident #23) of sixteen residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Resident #33 on 02/17/2026 and 2/19/2026. The facility failed to ensure the call light was in reach and accessible for Resident #23 on 02/17/2026. This failure could place the residents at risk of being unable to obtain assistance when needed, obtain help in the event of an emergency, and result in an increased risk of falls.

Inspectors wroteBased on observation, interview and record review the facility failed to maintain clinical records in accordance with accepted professional standards and practices that are complete and accurately documented for 3 (Residents #2, #7, and #38) of 5 residents reviewed for treatment administration. The facility failed to ensure staff accurately documented Resident's 2, #7, and #38's Medication Administration Record (MAR) the administration of controlled substance. The facility failed to ensure staff followed up with Resident's #2, #7 and #38 after narcotic pain medication administration for monitoring results and or complaints/symptoms for which the drug was administered, per facility policy. These failures could put residents at risk for medication errors and errors in care.

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 and to help prevent the development and transmission of communicable disease and infection for 1 (Resident #22) of 5 residents reviewed for infection control. The facility failed to ensure staff followed infection control practices of washing hands before performing patient care, performing hand hygiene with an alcohol-based hand sanitizer after glove use, and following proper steps for performing peri-care on a male resident (Resident # 22) during incontinent care. These failures could place residents at risk for infection due to improper care practices.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 31(East Hall room [ROOM NUMBER]) provided a minimum of 80 square feet of floor space per resident, in that: East hall room [ROOM NUMBER] was included in the facility's licensed capacity as a three-bed resident room and did not provide the minimum floor space required per resident. This failure could place residents at risk for restricted movement and limit the amount of resident use equipment and personal effects that could be accommodated in the room.

Inspectors wroteBased on interviews and record review, the facility failed to develop a comprehensive person-centered care plan that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan described the services that are to be furnished to attain and maintain the resident's highest practicable physical, mental, and psychosocial well-being. The facility failed to ensure Resident #1's comprehensive care plan described any specialized services or specialized rehabilitative services the nursing facility will provide because of PASARR recommendations. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 6 residents (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1's comprehensive care plan was developed within 7 days after the MDS assessment was completed. This failure could result in the residents not receiving proper care and services. Record review of Resident #1's face sheet revealed a [AGE] year-old male, admission date 11/26/2025, Diagnoses: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate are not greater than 5 percent. There were 2 errors out of 25 opportunities which resulted in an 8 percent error rate involving Resident #8. 1. LVN A failed to follow physician's order when she flushed Resident #8's PICC line with Heparin flush (blood thinner) 5 ml of 10u/ml. 2. LVN A failed to administer Meropenem ordered by physician for Resident #8 within time frame ordered. These failures could place residents at risk of medication side effects from not receiving their medications as prescribed according to physician's orders and manufacturers recommendations.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents were free of any significant medication errors for 1 of 10 residents reviewed for medication administration. (Resident #8). LVN A failed to follow physicians orders when she flushed Resident #8's PICC line with Heparin flush (blood thinner) 6 ml of 10u/ml. This failure could place residents Resident #8 at risk of their health and safety being jeopardized.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that drugs and biologicals used in the facility were secured in locked compartments and permit only authorized personnel to have access to the keys for 1 of 2 medication carts observed for medication storage. The facility did not ensure the East Hall Medication Cart was locked and secured. This failure could place the residents at risk of gaining access to unlocked medications not prescribed to them.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 31(East Hall room [ROOM NUMBER]) provided a minimum of 80 square feet of floor space per resident, in that: East hall room [ROOM NUMBER] was included in the facility's licensed capacity as a three-bed resident room and did not provide the minimum floor space required per resident. This failure could place residents at risk for restricted movement and limit the amount of resident use equipment and personal effects that could be accommodated in the room.

Inspectors wroteBased on observation, interview, and record review, the facility failed to consult with the resident's physician, or the resident's representatives regarding a change in condition for 1 (Resident #1) of 3 residents reviewed for notification of changes. The facility did not consult with Resident #1's Physician or Resident Representative regarding a pressure ulcer that was identified on 03/04/2024 and re-assessed on 04/07/2024. This failure could place residents who presented with pressure ulcers at risk for not receiving appropriate care and interventions.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary treatment and services, based on the comprehensive assessment and consistent with professional standards of practice, to prevent development of pressure injuries for 1 of 7 (Residents #1) residents reviewed for pressure injuries. The facility failed to notify Resident #1's Physician, Resident Representative and Hospice services after identification of wound on Resident #1's right heel. The facility failed to obtain orders for wound care for Resident #1's right heel. The facility failed to perform routine wound care for Resident #1's right heel. The facility failed to complete weekly skin assessments for Resident #1. This failure could place residents who had pressure injuries at risk for new development or worsening of existing pressure injuries.

Inspectors wroteBased on interviews, and record reviews, the facility failed to complete a comprehensive assessment within 14 days after a significant change in the physical condition for 1 of 2 residents (Resident #1) whose records were reviewed for assessments. The facility failed to recognize and re-assess Resident #1 after a pressure ulcer was identified, a fall with major injury occurred and aggressive behaviors presented. This failure placed residents at risk for not developing interventions to meet their needs for care assistance and treatments.

Inspectors wroteBased on interview and record review, the facility failed to develop a comprehensive care plan within 7 days after completion of the comprehensive assessment for 1 of 3 residents (Resident #1) whose records were reviewed for assessments and care plans, as well as having an IDT team present at the care conference. The facility failed to ensure that Resident #1 had an Intradisciplinary Team care conference after Residents #1's Significant Change MDS dated [DATE]. This failure could place residents at risk of not have having their care plans completed accurately and timely.

Inspectors wroteBased on observation, record review and interview, the facility failed to maintain wound care records on each resident that are accurately documented for 1 of 3 residents (Resident #1) reviewed for records. The facility failed to document that Resident #1 had wound care. This failure to maintain accurate records could affect Residents by receiving inadequate care and services.

Inspectors wroteBased on observations, interviews, and record reviews, 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 for 1(Resident #1) of 2 residents reviewed for infection control practice. CNA (Certified Nurse Assistant) A failed to perform hand hygiene and change her gloves at the appropriate times while providing incontinence care for Resident #1. These failures placed residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as possible and each resident received adequate supervision and assistance devices to prevent accidents for 1 of 5 residents (Resident #13) whose records were reviewed for quality of care. 1. The facility failed to ensure a physician-ordered wander guard was in place for Resident #13. 2. The facility failed to prevent Resident #13 from leaving the facility unaccompanied on 10/05/23. This failure resulted in Immediate Jeopardy on 9/30/23. The noncompliance was determined to be past noncompliance (PNC). The noncompliance began on 9/30/23 at 6:37 PM and ended on 10/06/23. The facility had implemented the actions that corrected the noncompliance before the surveyor's entrance into the facility on [DATE]. [...]

Inspectors wroteBased on record review and interviews, the facility failed to use the services of a registered nurse (RN), for at least 8 consecutive hours a day, 7 days per week for 2 of 3 months (April 2023 and May 2023) reviewed for RN coverage, in that: The facility failed to ensure that an RN worked 8 consecutive hours a day, seven days a week for 8 of 61 days during April 2023 and May 2023. This failure placed the residents at risk for not having decisions made that would have required an RN to make in the management of the residents' healthcare needs and in managing and monitoring of the direct care staff.

Inspectors wroteBased on observation and interviews the facility failed to provide a safe, clean, comfortable and homelike environment for 1 of 6 residents (Resident #28) whose room was observed for cleanliness, in that: Resident #28 had feces on his bed linens for 2 days. This facility failure placed residents at risk for decreased feelings of well-being and sense of self-worth within their living environment.

Inspectors wroteBased on interview and record review, the facility failed to coordinate the assessment of 1 of 3 residents (Resident #30) reviewed for the pre-admission screening and resident review (PASRR) program and PASRR assessments and evaluations. The facility did not identify Resident #30 as having mental illness that would require a PASRR Form 1012 (a form which is used to determine whether the individuals dementia diagnosis is the primary diagnoses that would take precedence over a mental illness diagnosis), or a new PL1 form. This failure could affect residents with psychiatric diagnoses who may not be evaluated for PASRR services and place them at risk of not receiving services for care and treatment.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours for 1 of 2 residents (Resident #33) whose records were reviewed for recent admission to the facility, in that: Resident #33 was admitted to the facility on [DATE] and a baseline care plan had not been developed within 48 hours following her admission to the facility. This failure placed the resident at risk for not receiving care and services to meet her needs and to promote her physical and mental health and well-being within her new living environment.

Inspectors wroteBased on interview and record review the facility failed to ensure, based on the comprehensive assessment of a resident, that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan and the residents' choices for 1 of 1 resident (Resident #28) reviewed for quality of care, in that: The facility failed to ensure Resident #28 received an enema for a complaint of constipation when requested. This failure could place residents at risk of unmet care needs and constipation.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure parenteral fluids were administered consistent with professional standards of practice and in accordance with physicians' orders, the comprehensive person-centered care plan and the resident's goals and preferences for 1 of 1 resident (Resident #30) reviewed for receiving parenteral (administered through a vein) fluids. The facility failed to ensure Resident #30's midline intravenous catheter (an intravenous catheter that is suitable for long term infusion therapy) dressing to his right upper arm, was changed every 7 days as ordered by his physician. This failure could place residents at risk of complications such as infection and/or sepsis and midline catheter displacement and/or infiltration.

Inspectors wroteBased 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, the comprehensive person-centered care plan, the resident's goals, and preferences for 1 of 3 residents (Resident #27) reviewed for respiratory care, in that: Resident #27 did not have physician's orders for oxygen administration. This facility failure could place residents who received respiratory treatments at risk for receiving incorrect or inadequate oxygen support and could result in a decline in health status.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that meet the needs of each resident for 1 of 8 residents (Resident #8), reviewed for pharmacy services. The facility failed to accurately and timely complete documentation of controlled drug administration for 1 resident and monitoring of controlled medications stored on 1 ( [NAME] Hall) of 2 Medication carts checked for narcotic reconciliation. This failure could place residents at risk of medication overdose, medication under-dose, and ineffective therapeutic outcomes.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that controlled drugs listed in the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse were stored in separately locked, permanently affixed compartments in 1 out of 2 facility medication rooms. There was injectable lorazepam in East Hall medication room refrigerator that was not in a separately locked, permanently affixed compartment. The facility's failure could place residents at risk for drug diversion, drug overdose, and accidental or intentional missed doses or administration to the wrong resident.

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 2 of 2 residents (Residents #7 and #183) reviewed for infection control practices, in that: CNA G failed to perform proper hand hygiene before resident contact and after glove changes while providing incontinence care to Resident #7. CNA D failed to remove soiled gloves and perform hand hygiene before adjusting Resident 183's sheet to provide privacy and then reapplying a new brief. This failure could place residents at risk for the spread of infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure 1 of 1 multiple bed resident room (East Hall room [ROOM NUMBER]) provided a minimum of 80 square feet of floor space per resident, in that: East hall room [ROOM NUMBER] was included in the facility's licensed capacity as a three-bed resident room and did not provide the minimum floor space required per resident. This failure could place residents at risk for restricted movement and limit the amount of resident use equipment and personal effects that could be accommodated in the room.