Avir at Carthage

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights 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 and ensured the services that were to be furnished attained and maintained the residents' physical, mental, and psychosocial well-being for 1 of 4 residents (Resident#32) reviewed for care plans. The facility failed to implement a person-centered care plan for Resident #32 by monitoring his thyroid function with lab tests as ordered by the physician. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain all mechanical, electrical, and patient care equipment in a safe operating condition for 1 of 1 kitchen reviewed for essential equipment. The facility did not ensure the gas stove in the kitchen was in a safe operating condition when on 09/19/25 three of ten burners did not light when turned on and on 09/16/25 two of ten burners did not light. This failure could place the residents at risk of a fire and not receiving their meals in a timely manner.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences except when to do so would endanger the health or safety of the resident or others for 1 of 6 residents (Resident #34) reviewed for reasonable accommodations of needs. The facility failed to ensure Resident #34 had a call light within reach. This failure could place residents at risk of possible falls, major injuries, hospitalization, and unmet needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure resident assessments accurately reflected the resident's status for 1 of 15 residents (Resident #40) reviewed for accuracy of assessments. The facility failed to accurately complete the MDS assessment to indicate Resident #40's wander alarm/ bracelet (wearable safety device that uses door sensors to send real time alerts to care givers when a resident with the bracelet leaves a designated area). This failure could place residents at risk of not receiving the appropriate care and services to maintain their highest level of well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 1 of 15 residents reviewed for ADLs. (Residents #2) The facility failed to trim and clean under Resident #2's fingernails. This failure could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident received adequate supervision using a mechanical lift (assistive device) to prevent accidents for 1 of 18 residents reviewed for accidents (Resident #2). The facility failed to ensure Resident #2 was safely transferred using a mechanical lift with 2-person transfer on 9/16/2025 at 7:55 AM. This failure could place residents at risk for injury or harm.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 8 residents reviewed for respiratory care. (Resident #47)The facility failed to ensure Resident #47 received continuous oxygen as ordered by the physician when his oxygen tank was empty on 9/16/25. This failure could place residents at risk of respiratory complications.

Inspectors wroteBased on observation, record review and interview the facility failed to store all drugs and biologicals in locked compartments for 1 of 18 residents (Resident #14) reviewed for drug storage. The facility failed to securely store a white powder substance in a medication cup for Resident #14 located on bedside table. This failure could place residents at risk for access to medications/biologicals not approved for their health condition.

Inspectors wroteBased on observations, interviews, 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 1of 3 residents reviewed for infection control practices (Resident #3). The facility failed to ensure CNA G and CNA M donned a gown when they performed peri care on Resident #3. Resident #3 was on enhancement barrier precautions. These failures could place residents at risk of exposure to communicable diseases, cross-contamination, and infections.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure the resident environment remained free of accident hazards as possible, and each resident received adequate supervision to prevent elopement for 1 of 8 residents (Resident #1) reviewed for accident hazards and supervision. The facility failed to supervise and put measures in place to keep Resident #1 from eloping on 6/13/25. The facility failed to complete Resident #1's quarterly elopement risk assessment due after 12/27/25. Resident #1's elopement risk assessment was not completed until 06/13/25, after she had eloped from the facility. The noncompliance was identified as PNC. The IJ began on 06/13/25 and ended on 06/17/25. The facility had corrected the noncompliance before the survey began. These failures could place the residents at risk for serious injury, serious harm, serious impairment, or death.

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 01/07/24, 01/13/24, 01/20/24, 1/21/24, 02/03/24, 02/04/24, 02/10/24, 02/24/24, 03/02/24, 03/03/24, 03/16/24, 03/17/24, 03/31/24, and 07/13/24. This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the resident's status for 2 of 14 resident reviewed for assessments. (Resident #8 and Resident #15) The facility failed to ensure Resident #8's falls on 05/29/24 and 07/07/24 were coded on her MDS. The facility failed to ensure Resident #15's falls on 05/09/24, 06/26/24, and 07/06/24 were coded on her MDS. The facility failed to ensure Resident #15's diagnosis of dementia (is a general term for loss of memory, language, problem-solving and other thinking abilities that are severe enough to interfere with daily life) was coded on her MDS. The facility failed to ensure Resident #15 was coded for receiving an anticoagulant (medicines that help prevent blood clots) not antiplatelet (medications that prevent platelets from sticking together and forming blood clots). [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to develop, and implement a comprehensive care plan to meet the medical, nursing, mental and psychosocial needs for 3 of 14 residents (Resident #15, Resident #23, and Resident #35) reviewed for care plans. 1. The facility failed to care plan Resident #15's hearing problem and use of hearing aids. 2. The facility failed to care plan Resident #23's hearing problem, impaired vision, on antidepressant (is a type of medicine used to treat clinical depression) and oral antidiabetic (used in the treatment of diabetes mellitus to control glucose levels in the blood) medication, dental issue, and shortness of breath on exertion. 3. The facility failed to care plan Resident #35's impaired vision. [...]

Inspectors wroteBased on observation, interviews 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 for kitchen sanitation in that: 1. The facility failed to ensure ice machine was functioning properly and preventing ice from spilling out onto the floor. 2. The facility failed to ensure minimal black carbon buildup on iron gas stovetop and debris cleared from under burner. 3. The facility failed to ensure food was properly labeled, dated, and stored in a resident personal refrigerator. These failures could place residents who received meals from the kitchen at risk for chemical contamination and food-borne illness.

Inspectors wroteBased on observations, interviews, 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 2 of 2 residents (Resident #19 and Resident #23) reviewed for incontinent care and 3 of 5 (Resident #5, Resident #18, and Resident #22) reviewed for Covid-19 infection control practices. 1. The facility failed to ensure MA A wore an N95 mask when entering Covid positive Resident #19 and #22's room. 2. The facility failed to ensure MA A changed her mask after leaving Covid positive Resident #19 and #22's room and entering another non-isolation room. 3. The facility failed to ensure CNA P and Housekeeper Q wore proper PPE in Resident #5's room on 08/18/24 and 08/19/24. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents had the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for 2 of 14 residents (Resident #8 and Resident #15) reviewed for reasonable accommodations. The facility failed to ensure Resident #8 and Resident #15's call light was placed within reach. This failure could place residents at risk for unmet needs.

Inspectors wroteBased on interview and record review, the facility failed to ensure an encoded, accurate, and complete MDS discharge assessment was electronically completed and transmitted to the CMS System within 14 days after completion for 1 of 1 resident (Resident #44) reviewed for discharge MDS assessments. The facility did not ensure Resident #44's discharge MDS assessment was completed and transmitted within 14 days of completion. This failure could place residents at risk of not having records completed and submitted in a timely manner as required.

Inspectors wroteBased on interviews and record review, the facility failed to ensure a registered nurse signed and certified that the MDS assessment was completed for 1 of 1 resident (Resident # 44) reviewed for MDS completion. The facility failed to ensure the RN signed Resident #44's discharge MDS assessment as completed. This failure could place residents at risk for incomplete or inaccurate documentation that does not completely reflect the resident's status.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 5 (Resident #23) residents reviewed for quality of care. The facility failed to ensure Resident #23 had daily blood sugar glucose checks due to being on an antidiabetic (help manage blood sugar (glucose) levels in people who have Type 2 diabetes) medication. This failure could place residents of risk for not receiving appropriate care and treatment for hyperglycemia (when there's too much sugar (glucose) in your blood) or hypoglycemia (when your blood sugar (glucose) level falls too low for bodily functions to continue).

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore continence to the extent possible for 2 of 2 residents reviewed for urinary and bowel incontinence (Resident #18 and #32). 1. The facility failed to ensure Resident #18 was not found excessively wet on 08/19/24. 2. The facility failed to ensure CNA C performed proper incontinent care by ensuring Resident #32 was completely clean after bowel movement and before placing a new brief on 8/19/2024. These failures placed residents who required assistance with incontinent care at risk for urinary tract infections, skin breakdown, and hospitalization.

Inspectors wroteBased on interview and record review, the facility failed to ensure that nurse aides were able to demonstrate competency in skills and techniques necessary to care for residents' needs for 1 (CNA B) of 2 staff reviewed for demonstration of skills and techniques necessary for residents' needs. The facility failed to ensure CNA B identified and addressed a change in condition and failed to report to LVN L, when Resident #18's pink tinged urine visualized during incontinent care on 08/19/24 which delayed physician notification and treatment. This failure could place residents at risk for not receiving the appropriate care and services to maintain their health and safety.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering, and receipt of all drugs and biologicals, to meet the needs of 1 of 14 residents (Resident #9) reviewed for pharmacy services. The facility failed to ensure MA A signed off on the Narcotic Drug Record for Resident #9's lacosamide (a medication used to reduce the number and severity of seizures) medication when the last dose on the medication card was administered. This failure could place residents who received medications at risk of missing medications or missing doses of medications and staff being unable to reconcile controlled substance counts.

Inspectors wroteBased on interview, and record review, the facility failed to ensure each resident's drug regimen was free from unnecessary medications (a medication used in excessive doses and including duplicate therapy or for excessive duration; or without adequate monitoring, or without adequate indications for its use; or in the presence of adverse consequences which indicated the dose should be reduced or discontinued) for 1 of 5 residents reviewed for unnecessary medications. (Resident #35) The facility failed to ensure Resident #35 did not receive Minocycline, an antibiotic, without an indication of use and an excessive duration. The facility failed to ensure Resident #35 did not receive Acidophilus, a type of probiotic (good bacteria) found in the human gut, mouth, and vagina, and also in certain foods, for an excessive duration. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for 2 of 14 residents (Resident # 23 and Resident #33) reviewed for pharmacy services. The facility failed to safely store wound cleanser in a locked compartment in a clean, safe, and sanitary manner for Resident #23 and Resident #33. This failure could place residents at risk for misuse of medication and overdose, adverse reactions of medications, and not receiving the therapeutic benefit of medications.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide basic life support, including CPR to a resident requiring emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the residents advanced directives for 1 of 4 residents reviewed for emergency care ( Resident #1) The facility failed to assess and immediately initiate CPR when Resident #1, who was a full code, was found unresponsive in the dining room on 08/11/24 at 7:10 a.m. CPR was not initiated until EMS arrived (12 minutes after the resident was found unresponsive). Resident #1 was transported to the hospital, found to have large amounts of solid food in his airway, and pronounced deceased on [DATE] at 9:18 a.m. An Immediate Jeopardy (IJ) was identified on 08/15/24. The IJ template was provided to the facility on [DATE] at 6:10 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse. The facility failed to prevent LVN A, on 12/10/23, from verbally and physically abusing Resident #1 when she used foul language and threw ice at Resident #1. The facility failed to prevent LVN A, on or about 12/10/23, from verbally and physically abusing Resident #2 when she used foul language and threw an object at Resident #2. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. The facility had corrected the noncompliance before the survey began. These failures could place resident at risk for emotional distress, fear, decreased quality of life and further abuse.

Inspectors wroteBased on interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 2 of 10 residents (Resident #1 and Resident #2) reviewed for abuse. 1. The facility failed to ensure [NAME] B, DA C, and MA D immediately reported witnessed abuse towards Resident #1 to the abuse coordinator. 2. The facility failed to ensure Resident #1, and Resident #2 was free from abuse per the policy. 3. The facility failed to ensure the abuse coordinator obtained in writing or electronic format witness statements from [NAME] B, DA C, and MA D. 4. The facility failed to ensure, per their policy, to report alleged allegation of abuse towards Resident #2 to HHSC. The noncompliance was identified as PNC. The IJ began on 12/10/2023 and ended on 12/15/2023. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, were reported immediately, but not later than 2 hours after the allegation was made, if the events that caused the allegation involved abuse or resulted in serious bodily injury, or not later than 24 hours if the events that caused the allegation did not involve abuse and did 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 of 10 residents (Resident #2) reviewed for abuse and neglect. The facility failed to report Resident #2's abuse allegation within 24 hours to the state agency. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received the necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection, and prevent new ulcers from developing for 1 of 2 residents (Resident #160) reviewed for pressure injury. The facility failed to reposition Resident #160. The facility failed to have a low air loss mattress (is a mattress designed to prevent and treat pressure wounds) on admission for Resident #160. The facility failed to follow up on nutritional labs (albumin (is protein in your blood plasma) and total protein (test measures the sum of all types of proteins in the blood. Proteins are fundamental to the functioning of the body)) results for Resident #160. The facility failed to ensure Resident #160 did not have a wound infection. [...]

Inspectors wroteBased on observations, record reviews, and interviews, the facility failed to protect and promote the rights of the resident in an environment that promoted maintenance or enhancement of his or her quality of life for Anonymous Residents #1-6 and 2 of 18 residents (Resident #33 and Resident #46) reviewed for resident rights. The facility failed to protect and value Anonymous Residents #1-6, Resident #33, and Resident #46's private spaces from Residents #39 and Resident #52, who frequently wandered into residents' rooms and went through their belongings. This failure could place residents at risk for decreased quality of life, increased anxiety, and increased stress.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for 4 of 7 (Resident #36, Resident #37, Resident #42, Resident #160) residents and 1 of 6 Halls (Hall 1) reviewed for environment. 1. The facility failed to ensure resident #37 could close her bedroom door. 2. The facility failed to ensure Resident #36 did not have brown and orange stains on the wall. 3. The facility failed to ensure Resident #36 did not have a torn vent cover behind the headboard. 4. The facility failed to ensure Resident #42, and Resident #160 did not have torn walls of sheetrock. 5. The facility failed to ensure Resident #160 did not have brown and yellow stain on the wall. 6. The facility failed to ensure Resident #160 door was not obstructed by a footboard causing it not to completely close. 7. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents or hazards for 2 of 7 residents that wandered reviewed for supervision. (Resident #39 and Resident #52) 1. The facility failed to provide adequate supervision to continue to prevent Resident #39 from entering Resident #15's room following a previous incident on 5/31/23 where Resident #39 had put his hands around Resident #15's neck. 2. The facility failed to provide adequate supervision to prevent Resident #52 from exiting the building twice on 6/18/23. 3. The facility failed to provide adequate supervision to prevent Resident #39 and Resident #52 from entering Resident #46's room and going through her things, resulting in Resident #46 being pushed by Resident #52. These failures could place residents at an increased risk of injury.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide services by sufficient numbers of other nursing personnel, which included but not limited to nurse aides, on a 24-hour basis to provide nursing care to all residents in accordance with resident care plans for 5 of 17 residents (Residents #30, Resident #39, Resident #43, Resident #45, Resident #52) and Anonymous Resident Council members (AR 1-AR7) reviewed for care and services. The facility failed to provide sufficient staff on the 6a-2pm, 2pm-10pm, 10pm-6am (04/01/23-06/25/23) shifts to meet the needs of the residents who required assistance with activities of daily living. This failure could place residents at risk of infection, skin breakdown, low self-esteem, depression, embarrassment, and psychological harm.

Inspectors wroteBased on interview, and record review, the facility failed to use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week for 1 of 1 facility reviewed for RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 04/10/23, 06/04/23, 06/10/23, 06/24/23, 06/25/23. The deficient practice had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 6 of 18 residents and 7 anonymous residents reviewed for palatable food. (Anonymous Resident #1 - #7, Resident #22, Resident #25, Resident #35, Resident #38, Resident #50, and Resident #110) The facility failed to provide palatable food served to Resident #22, Resident #25, Resident #35, Resident #38, Resident #50, and Resident #110 who complained the food did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote resident self-determination through support of resident choice for 1 of 1 resident reviewed for self-determination. (Resident #45) The facility did not assist Resident #45 out of bed when he requested. This failure could place dependent residents at risk for feelings of lack of self-determination and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were free from abuse for 1 of 24 residents (Resident #18) reviewed for resident abuse. The facility did not ensure Resident #18 was free from abuse, as a result Resident #18 was verbally abused by DA J. This failure could place residents at risk of physical harm, mental anguish, and/or emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to ensure assessments accurately reflected the status for 2 of 2 residents reviewed for assessments. (Resident #6 and Resident #34) The facility failed ensure Resident #6's MDS assessment was properly coded for PASRR and medication classification. The facility failed to ensure Resident #34's MDS assessment was properly coded for having an indwelling catheter. These failures could place residents at risk of not having individual needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure the baseline care plan that included the instructions for resident care needed to provide effective and person-centered care was completed and provided to the resident and/or their representative for 1 of 2 residents reviewed for new admissions (Resident #160). The facility failed to complete Resident #160's baseline care plan within 48 hours of admission. This failure could place residents at risk of not receiving care and services to meet their needs.

Inspectors wroteBased on interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan to meet each resident's medical, nursing, mental and psychosocial needs for 1 of 17 residents reviewed for care plans. (Resident #13) The facility failed to implement the comprehensive person-centered care plan for Resident #13 by not weighing the resident weekly. This failure could place residents at risk of not having individual needs met, a decreased quality of life, and cause residents not to receive needed services

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide the necessary services to maintain personal hygiene for 2 of 12 residents reviewed for ADLs (Residents #43 and Resident #30). 1. The facility did not clean or trim Resident #43's fingernails. 2. The facility did not shave Resident # 30's facial hair. These failures could place residents who required assistance from staff for ADLs at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health.

Inspectors wroteBased on interview and record review, the facility failed to ensure dialysis service were provided consistently with professional standards of practice for 1 of 3 residents reviewed for dialysis services. (Resident #159) The facility failed to consistently document on Resident #159's dialysis communication form. This failure could place residents who received dialysis at risk for complications and not receiving proper care and treatment to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. There were 4 errors out of 26 opportunities, resulting in an 15.38% percent medication error involving 1 of 6 residents reviewed for medication pass. (Resident #45) The facility failed to administer scheduled medications in a timely manner for Resident #45. This failure could place residents at risk for inaccurate drug administration.

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 diseases and infections for 2 of 5 residents (Residents #43, Resident #160) reviewed for infection control practices. The facility failed to ensure CNA A kept Resident #160's indwelling catheter off the floor. The facility failed to ensure Resident #43 was provided water in a sanitary manner. These failures placed residents at risk for cross contamination and infection.