Avir at Garland

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse for a minimum of eight consecutive hours a day, seven days a week, for 5 days in a 3 month reporting period .The facility failed to have RN coverage on the following dates in 2025:-October 4, -November 01, 13, 18, and 19 2025. This failure could place residents at risk of not having their nursing and medical needs met, and not receiving proper care.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide pharmaceutical services (including procedures that ensured drugs and biologicals were accurately acquired, received, dispensed, and administered) to meet the needs of each resident for one medication room (hall 500-600 medication room) of two medication rooms and one supply room of one reviewed for pharmacy services. The facility failed to ensure expired medication administration supplies were removed from the facility medication room and the supply room. These failures could place residents at risk of infection and having possible adverse effects.

Inspectors wroteBased on observations, interviews and record review, the facility failed to ensure the assessment accurately reflected the resident's status for one (Residents #70) of four residents reviewed for smoking. 1. The facility failed to accurately assess Residents #70 for smoking safety. These failures could place smoking residents at risk of burn accidents related to smoking supervision.

Inspectors wroteBased on observations/interviews/record review, the facility failed to protect the resident's right to be free from mental abuse, verbal abuse, physical abuse, sexual abuse, deprivation of goods and services by staff, a resident, a visitor. The facility failed to ensure Resident #1 was free from abuse on 4/13/26, when Resident #2 struck and scratched her, which resulted in multiple bruises to her arm. This failure could place residents at risk of abuse and emotional distress.

Inspectors wroteBased on interviews and record reviews, 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 3 out of 5 residents (Residents #1, Resident #2 and Resident #3) reviewed for medication administration. The facility staff did not follow physician orders and administered Resident #1, four Warfarin pills on 03/08/26 and 03/09/26 instead of two. The facility staff did not watch Resident #1 take her medications. The facility staff did not watch Resident #2 take her Melatonin 3MG medication. The facility staff did not watch Resident #3 take his Zolpidem Tartrate 5mg medication. [...]

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 2 of 5 residents (Residents #1 and #2) reviewed for infection control practices. 1. RN A and CNA B failed to wear a gown while providing incontinence care to Resident #1, who was on EBP due to having pressure ulcers on her sacral area and foot.2. RN A failed to wear a gown while providing wound care to Resident #1, who was on EBP due to having pressure ulcers on her sacral area and foot.3. LVN C failed to wear a gown while providing wound care to Resident #2, who was on EBP due to having pressure ulcers on her sacral area and left ankle. [...]

Inspectors wroteBased on observations, interviews, 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 promoted maintenance or enhancement of his or her quality of life for 1 of 6 residents (Resident #6) reviewed for dignity. The facility failed to conceal Resident #6's catheter bag from lying in public view. This failure placed residents at risk of not having their right to a dignified existence and self-determination maintained.

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 other residents for three of ten residents (Residents #3, #4, and #5) reviewed for call systems access. The facility failed to ensure the call light system in Residents #3, #4, and #5's rooms was in a position that was accessible to the residents on 10/30/25. This failure could place the residents 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 ensure that residents, who needed respiratory care, were provided care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for four of seven residents (Residents #1 and #2) reviewed for respiratory care. The facility failed to ensure Resident #1's nasal canula and CPAP mask was properly stored in a bag when not in use on 10/30/25. The facility failed to ensure Resident #2's nasal canula was properly stored in a bag when not in use on 10/30/25. These failures could place residents at risk of respiratory infection and not having respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that each resident received adequate supervision and assistance devices to prevent accidents which resulted in sustained bleeding to the brain, a bruise to the scalp, and a bruising to the hands for 1 (Resident #1) of 4 residents reviewed for accidents. On 11/07/2025 Certified Nurse Aide (CNA) A attempted to perform a 1-person transfer, with a sliding board, on Resident #1 who required a 2-person transfer with a Hoyer (Mechanical lifting device to help workers transfer patients) lift for nursing staff. CNA A failed to request assistance from another staff member and was unable to complete the transfer successfully. Resident #1 fell on the floor and hit her head. Resident #1 was sent to the hospital where it was discovered that she had a traumatic brain hemorrhage. [...]

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 5 (Resident #58, #56, #54, #61, and #120) of 18 residents reviewed for Reasonable Accommodation of Needs. The facility failed to ensure the call light was in reach and accessible for Residents #58, #56, #54, #61, and #120. This failure could place the residents 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 ensure residents had the right to a safe, clean, comfortable, and homelike environment including but not limited to receiving treatment and supports for daily living safely for 9 of 12 resident rooms (Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9) reviewed for environment. The facility failed to ensure Resident room [ROOM NUMBER], #2, #3, #4, #5, #6, #7, #8, and #9 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 reviews, the facility failed to ensure that residents' environment remained free of accident hazards as was possible for 3 of 6 residents (Resident #17, #26, and #34) reviewed for accident prevention. The facility failed to ensure Resident #17, and Resident #26 had physician orders for the use of a scoop mattress for fall prevention. The facility failed to ensure Resident #34 had a fall mat placed alongside her bed for fall prevention. These failures could prevent the resident from having an environment that was free and clear of accidents and hazards.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that residents, who needed respiratory care, were provided such care consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for five (Resident #10, #11, #32, #49, and #120) of ten residents reviewed for Respiratory Care. 1. The facility failed to ensure Resident #120's nasal canula (flexible tube used to deliver oxygen to the nose through two prongs), for the oxygen machine was placed in a sanitary bag to avoid contamination while not in use on 3/16/2025. 2. The facility failed to ensure Resident #10's humidifier bottle (a medical device designed to increase the moisture level in supplemental oxygen) had water in it on 03/16/2025. 3. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to store, prepare, distributed, and serve food in accordance with professional standards for food service safety for the facility's only kitchen, reviewed for food and nutrition services. 1. The facility failed to ensure the ice scoop for the ice machine in the facility kitchen was cleaned and exposed to air-borne contaminants. 2. The facility failed to ensure the ice machine was thoroughly cleaned. 3. The facility failed to ensure the kitchen floor and walls were cleaned. 4. The facility failed to ensure kitchen cooking equipment was cleaned. 5. The facility failed to place a cover on top of the tea dispenser to avoid air borne contaminants. 6. The facility failed to ensure food in the refrigerator was labeled and dated. 7. The facility failed to ensure foods in the freezer was sealed from air-borne contaminants. [...]

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 two of twelve (Resident #42 and Resident #15) residents reviewed for infection control. 1. The facility failed to ensure CNA D did not use gloves taken from the pocket of her scrub top while providing incontinence care to Resident #42 on 03/17/2025. 2. The facility failed to ensure CNA F changed her gloves and performed hand hygiene while providing incontinence care to Resident #15 on 03/17/2025. This failure could place residents at risk of cross-contamination and development of infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to treat each resident with respect, dignity, and care in a manner and environment that promoted maintenance or enhancement of his or her quality of life for one (Resident #50) of nine residents reviewed for Privacy. The facility failed to ensure RN B assessed and flushed Resident #50's midline catheter (a device inserted in the veins used for treatment) inside the resident's room on 03/17/2025. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure assessments accurately reflected the resident's status for one (Resident #43) of eight residents reviewed for Accuracy of Assessments. The facility failed to ensure Resident #43's Quarterly MDS assessment dated [DATE] accurately reflected that the resident had an external catheter (non-invasive device used to manage urinary incontinence such as Purewick). This failure could place the resident at risk for not receiving care and services to meet their needs, diminished function of health, and regression in their overall health.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth 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 a resident for two (Resident #11 and Resident #50) of eight residents reviewed for Care Plans. 1. The facility failed to ensure Resident #50 smoking cigarettes at the facility was care planned. 2. The facility failed to ensure Resident #11's breathing treatments were care planned. These failures could place the residents at risk of not receiving the necessary care and services needed.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that one (Probiotic) of one medication reviewed for Medication Storage was stored properly. The facility failed to ensure that the Probiotics with an instruction to refrigerate after opening was stored in the refrigerator. These failures could place the residents at risk of not receiving the full benefit of the medications or supplement.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to provide the right to personal privacy which includes accommodations during personal care for one (Resident #1) of ten residents reviewed for Privacy. The facility failed to ensure CNA A and CNA B provided privacy when they transferred Resident #1 in the hallway on 02/27/2025. This failure could place the residents at risk of not having their personal privacy maintained during medical treatment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistance devices to prevent accidents for one (Resident #1) of two residents reviewed for elopements. The facility failed to ensure Resident #1 received adequate supervision and remained in the facility's secured care unit, which resulted in her elopement from the facility on 10/04/2024. The facility failed to provide adequate supervision to Resident #1 to ensure Resident #2 did not facilitate Resident #1's elopement on 10/04/2024. The noncompliance was identified as PNC IJ. The noncompliance began and ended on 11/25/2024. The facility had corrected the noncompliance before the investigation began. This failure could place residents at risk of injury and a decreased quality of life.

Inspectors wroteBased on observation, interview, 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 kitchen sanitation. The facility failed to ensure the beverage dispenser, prepared for residents, was cleaned and changed out in a timely manner in observation on 11/21/2024 at 12:30 PM. These failures could place residents at risk for food-borne illnesses.

Inspectors wroteBased on interview and record review the facility failed to ensure all alleged violations involving abuse, neglect, exploitation or mistreatment were reported immediately but not later than two 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 to the administrator of the facility, other officials and State Survey Agency for two (Residents #2 and #3) of six reviewed for reporting alleged abuse, neglect, or mistreatment. The facility Administrator failed to report to HHSC an alleged altercation between Resident #2 and Resident #3 on 11/23/2024 after it was reported to him by facility's ADON. [...]

Inspectors wroteBased on interview and record review the facility failed to thoroughly investigate alleged violations and report the results of the investigation to the administrator or his or her designated representative to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to immediately consult with the resident's physician; and notify, consistent with his or her authority, when there was an accident involving the resident which resulted in injury and had the potential for requiring physician intervention for one (Resident #1) of six residents reviewed for Change in condition. LVN B failed to notify Resident #1's Doctor on 08/02/24 after CNA A asked her to assist with picking Resident #1 off the floormat and putting her back to bed. Subsequently, Resident #1 was sent to the hospital on [DATE] and currently at the hospital diagnosed with two fractures (Tibia and Fibula) of her left lower leg. An Immediate Jeopardy (IJ) was identified on 08/12/24. An IJ Template was provided to the facility on [DATE] at 12:10 pm. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure the resident had the right to be free from neglect as defined in this subpart for one (Resident #1) of six residents reviewed for Neglect. CNA A failed to ensure Resident #1 did not fall out of bed on 08/02/24 while she was providing incontinent care and LVN B failed to document assessing Resident #1's fall, LVN B failed to notify Resident #1's Doctor, LVN B failed to complete an incident report, and LVN B failed to notify the oncoming Nurse, DON, and Administrator about Resident #1's fall. Subsequently, Resident #1 was sent to the hospital 08/08/24 and was diagnosed with two fractures Tibia (Shinbone) and Fibula (Calf bone) of her left lower leg. An Immediate Jeopardy (IJ) was identified on 08/11/24. An IJ Template was provided to the facility on [DATE] at 3:38 pm. [...]

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to implement written policies and procedures that prohibit neglect for one (Resident #1) of six residents reviewed for Neglect. CNA A and LVN B failed to prevent neglect, such as ensuring Resident #1 received the necessary care and services to prevent harm and LVN B's failure to notify the oncoming Nurse, DON and Administrator about Resident #1's fall on 08/02/24. Subsequently Resident #1 sustained fractures of her Tibia (Shinbone) and Fibula (calf bone) of her left lower leg and was taken to the hospital on [DATE]. An Immediate Jeopardy (IJ) was identified on 08/11/24. An IJ Template was provided to the facility on [DATE] at 3:38 pm. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices for one (Resident #1 ) of six residents reviewed for Quality of Care. CNA A failed to provide incontinent care with a second staff member assisting, which resulted in Resident #1 falling out of bed. And LVN B failed to notify Resident #1's Doctor on 08/02/24 after CNA reported Resident #1 on the floor and assisted with getting Resident #1 on the floor. LVN B did not complete and document doing a head to toe assessment and incident report and did not monitor the resident or do neuro checks and notify other nursing staff to continue monitoring the resident. [...]

Inspectors wroteBased on interviews, and record review, the facility failed to review and revise each assessment, including comprehensive and quarterly review assessments by the interdisciplinary team for one (Resident #1) of six residents reviewed for care plans. The facility failed to ensure Resident #1's care plan was revised after her MDS Assessment reflected she was Dependent; 2 person assist for Bed mobility and incontinent care. This failure could place the resident at risk of their current individual needs not being met, causing falls, which could result in a decline in their health and psycho-social well-being.

Inspectors wroteBased on interview and record review, the facility failed to maintain the services of a Registered Nurse (RN) 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 ensure the facility maintained the required RN coverage for 9 days between August 2023 - January 2024. This failure placed residents at risk of not receiving higher levels of patient care.

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 4 (Resident #24, Resident #53, Resident #43, and Resident #38) of 10 residents observed for infection control. 1. The facility failed to ensure MA A sanitized the blood pressure cuff between Resident #24, Resident # 53, and Resident #43. 2. The facility failed to ensure LVN A wiped Resident #38's bottom away from the wound in the sacrum. 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 ensure residents with pressure ulcers received care and treatment consistent with professional standards of practice to promote healing and prevent further development of skin breakdown or pressure ulcers for one (Resident #38) of one resident reviewed for pressure ulcers. The facility failed to ensure LVN A cleaned the pressure ulcer on Resident #38's right hip from inside to outside. This failure could place the residents with pressure ulcers at risk for worsening of existing pressure ulcers.

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 1 (Resident #10) of 3 residents reviewed for adequate supervision in that: CNA A and CNA B failed to ensure Resident #10 did not swing around in the Hoyer lift sling during a transfer from the bed to the wheelchair. This failure could place residents at risk for decline in health, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services that assured accurate and timely acquiring and receiving of all medications to meet the needs of the two residents (Residents # 3 and Resident #56) of five residents reviewed according to facility policy and federal regulations to ensure accurate and timely dispensing of medications according to physician orders. The facility failed to ensure MA B re-ordered medications on a timely manner for Resident #3 (Donepezil 5 mg) and Resident #56 (Januvia 50 mg). This failure could place the residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observation, record review and interview the facility failed to ensure that a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable; and a resident with pressure ulcers receives necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #2) of seven residents reviewed for pressure ulcers. The facility failed to reposition Resident #2 every 2 hours. Resident #2 had a pressure ulcer to his buttocks. This failure placed residents at risk for development and worsening of the pressure ulcers.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to ensure residents received adequate supervision to prevent accidents for one (Residents #1) of four residents reviewed for elopement. 1. The facility failed to ensure Resident #1who had severe cognitive impairment and lacked safety awareness eloped from the facility on 10/22/23 at 5:53 p.m. and was located by police on 10/24/23 at an unknown location and taken to the hospital for evaluation. 2. The facility failed to assess Resident #1's risk for elopement quarterly according to their policy/procedure. 3. The facility failed to ensure staff were trained and able to demonstrate competency in elopement and supervision. An Immediate Jeopardy was identified on 10/24/23 at 4:02 p.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to develop and implement a person-centered comprehensive care plan for each resident that included measurable objectives and timeframes to meet a resident's medical, nursing, mental and psychosocial needs that were identified in the comprehensive assessment for one (Resident #1) of three residents reviewed for care plans. Resident #1's care plan did not address his Hospice services. This failure could place residents at risk of not receiving individualized care and services to meet their needs.