Avir at Gonzales

Inspectors wroteBased on observation, interview, and record review, the facility failed to post the current nurse staffing data for 1 of 1 facility, in that: The nurse staffing data upon entrance on 6/16/26 was dated 6/9/26. This deficient practice could place residents at risk by not providing adequate staffing information for the residents, staff, and visitors to ensure that resident care needs are met. Based on observation, interview, and record review, the facility failed to post the current nurse staffing data for 1 of 1 facility, in that: The nurse staffing data upon entrance on 6/16/26 was dated 6/9/26. This deficient practice could place residents at risk of not receiving appropriate care by not providing adequate staffing information for the residents, staff, and visitors to ensure that resident care needs are met.

Inspectors wroteBased on interviews and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice for 2 of 3 residents (Resident #1 and Resident #4) reviewed for dental services. The facility did not ensure Resident #1's physician was contacted for an order to withhold blood thinners prior to dental extractions on 5/19/26. The facility did not ensure Resident #4's physician was contacted for an order to withhold blood thinners prior to dental extractions on 5/19/26. This failure could place residents at risk of bleeding and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good grooming and personal hygiene for 1 of 5 residents (Resident #1) reviewed for ADLs. The facility failed to provide Resident #1 with assistance with the bathroom for more than 40 minutes following his second verbal request to CNA A on 1/02/2026. This failure could affect and diminish the resident's quality of life by potentially placing the resident at risk of infections, skin breakdown and/or it can make the resident feel neglected affecting their mental health and overall psychosocial well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure RN coverage of eight (8) hrs daily and a full time DON for eight days (11/1/25, 11/2/25,11/6/25,11/9/25,11/12/25, 11/13/25,11/17/25, and 11/18/25) in November 2025 for 1 of 1 facility. The facility failed to ensure RN 8 hour daily coverage and a full time DON in the facility for eight days in November 2025. This deficient practice could place residents at-risk of not having their care needs assessed by a licensed RN on a daily basis.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure an adequate communication system to allow residents to call for staff assistance for 3 of 9 rooms (Rooms# 108,109, and 206) reviewed on the three resident hallways for an operating call light system. The facility failed to ensure Resident rooms # 108, 109, and 206 had a fully functional call light notification system. This deficient practice could place residents at-risk of not being able to call for staff assistance to meet care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with resident rights, that included measurable objectives and time frames to meet residents' medical, nursing and mental and psychosocial needs that were identified in the comprehensive assessment, for 3of 8 residents (Residents #1, #6, and #3) reviewed for comprehensive care plans. 1. The facility failed to ensure Resident #1 had a care plan accessible in his current active record. 2. The facility failed to ensure that Resident #6's diagnoses of anxiety and depression, including a past history of self-harm, were focus areas on the resident's comprehensive care plan. 3. The facility failed to develop and implement a care plan to reflect Resident #3's surgical removal of his kidneys. [...]

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 nursing services. The facility failed to use the services of an RN as required for 13 days during the period between 3/1/2025 through 7/20/2025. This could result in residents not receiving the needed care and services to meet their needs and could result in illness, a decline in health, and in quality of care.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that the medication error rate was not five percent or greater. The facility had a medication error rate of 12% based on 3 errors out of 25 opportunities, which involved 2 (Residents #1 and #11) of 4 residents reviewed for medication errors, in that: 1. Medication aide-B (MA-B) administered Resident #11 his medication Omeprazole (a medication used to reduce the amount of acid produced by the stomach and recommended to be taken on a empty stomach before a meal) late by 1 hour and 48 minutes. 2. MA-B administered Resident #1's Refresh Optive Mega-3 eyedrops (a medication to relieve eye dryness), late by 4.5 hours. 3. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure the resident had the right to be informed in advance of the risks and benefits of proposed care, of treatment and treatment alternatives or treatment options, and to choose the alternative or option preferred for 1 of 8 Residents (Resident #6) whose records were reviewed for informed consent. The facility failed to ensure psychoactive medication consents for Resident #6 were signed and dated by her POA (Power of Attorney) for the use of: Seroquel (antipsychotic medication); Buspar (anti-anxiety); Zoloft (anti-depressant); Trazodone (anti-depressant); and Depakote (anti-convulsant also used to treat mood disorder) This failure could place residents at risk for receiving psychoactive medications without consent and knowledge of side effects.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 1 resident (Resident #6) reviewed for PASRR assessments. The facility did not refer Resident #6 to the appropriate state-designated mental health authority for review when she was admitted with diagnoses including: Psychotic Disorder with delusions due to known physiological condition (mental disorder which consists of a belief or altered reality that is persistently held despite evidence to the contrary); Major Depressive Disorder (mental health disorder characterized by persistently depressed mood or loss of interest in activities); and Anxiety Disorder (condition with intense, excessive, and persistent worry and fear about everyday situations). This failure could place residents at risk of not being evaluated and receiving needed PASRR services.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure that all drugs and biologicals used in the facility, were labeled and stored in accordance with professional standards for 1 (Hall 300 Nurse's medication cart) of 3 medication carts reviewed for medication storage. The facility failed to ensure one controlled medication Morphine Sulfate 20mg/5ml oral suspension for Resident #8 was removed from the medication cart when it had expired on 12/28/2024. This failure could place residents at risk of not receiving the therapeutic benefit of medications.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption, for 2 of 3 residents (Residents #4 and #15) reviewed for personal food policy, in that: 1. Resident # 4's personal refrigerator located in her room revealed food item of a glass jar of Picante Sauce which had been opened with a Best Use By Date of February 9,2025. There was no label or date of when the jar had been opened. 2. Resident # 15's personal refrigerator located in his room revealed food item of a Styrofoam cup covered with clear plastic wrap with white liquid inside it. There was no label or date identifying the name or date. These failures could place residents at risk of foodborne illness due to consuming foods which might be spoiled.

Inspectors wroteBased on interviews and record review the facility failed in accordance with accepted professional standards and practices, to maintain medical records on each resident that are complete and accurately documented, for 1 of 8 residents (Resident #1) reviewed for clinical records. The facility failed to ensure Resident #1's application of TED hose was accurately documented on his Medication Administration Record (MAR) for 23 of 23 daily entries in July 2025. This failure could place the residents at risk of not receiving the care and services needed due to inaccessible and inaccurate clinical records.

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 2 of 6 residents (Residents #4 and #24) reviewed for infection control: 1. The facility failed to maintain proper infection control procedures when LVN-A place Resident #4's open left heel wound directly onto the Resident's bedspread to during wound care treatment. 2. The facility failed to ensure MA-B sanitized the blood pressure cuff per facility protocol before and after checking Resident #24's blood pressure. 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 the comprehensive assessment accurately reflected the resident's status for 1 of 5 Residents (Resident #1) whose assessment records were reviewed. The facility failed when nursing staff did not code on Section GG of MDS Comprehensive assessment dated [DATE] that Resident #1 had functional limitation in range of motion to her upper extremity. This deficient practice could affect residents and contribute to residents not receiving care and services as needed.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan and the residents' goals and preferences for 3 of 8 residents (Residents # 2, #3 and #7) reviewed for respiratory therapy. 1. The facility failed to ensure Resident #2 had a physician order, was care planned or had an oxygen safety sign on the resident's room door. 2. The facility failed to ensure Resident #3 had a physician order, was care plan or had an oxygen safety sign on the resident's room door. 3. The facility failed to ensure Resident #7 had a care plan or oxygen safety sign on the door. These deficient practices could place residents at risk of receiving incorrect or inadequate oxygen support which could result in a decline in health.

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 2 of 8 residents (Resident #2 and Resident #6) reviewed for reasonable accommodation of resident needs. 1. The facility failed to ensure Resident #2 had access to his call light which was draped over his nightstand outside of the resident's reach. 2. The facility failed to ensure Resident #6 had access to her call light which was wrapped around the call light plug on the wall, behind Resident #6 and outside of her reach. These deficient practices could place residents at risk of not maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, 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 for 2 of 8 residents (Residents #1 and #4) reviewed for care plans. 1. The facility failed to ensure a care plan was developed to address Resident #1's enhanced barrier precautions which required staff to utilize gowns and gloves when direct care was provided. 2. The facility failed to ensure a care plan was developed to address Resident #4's enhanced barrier precautions which required staff to utilize gowns and gloves when providing direct care. These deficient practices could place residents at risk of an infection.

Inspectors wroteBased on interview and record review, the facility failed to promote the residents' right to receive mail, for 1 of 1 facility review for residents' right to receive mail, in that: Facility staff did not distribute mail received on Saturdays to the residents. This deficient practice could result in residents not receiving mail in a timely manner and a diminished quality of life.

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 nursing services. The facility failed to use the services of an RN as required, for 10 days, during the period between 3/1/2024 through 5/31/2024. This could result in resident's not receiving the needed care and services to meet their needs and could result in illness, a decline in health, and in quality of care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the medication error rate was not five percent or greater. The facility had a medication error rate of 10% based on 3 errors out of 30 opportunities, which involved 3 of 4 residents (Resident #3, Resident #22 and Resident #9) reviewed for medication errors. 1. Medication Aide D failed to administer medications as ordered to Resident #3 by administering hydrocodone (a treatment for Pain) )1 hour and 20 minutes after the scheduled time. 2. Medication Aide D failed to administer medications as ordered to Resident #22 by administering Duloxetine (a treatment for Depression and Nerve Pain) 1 hour and 42 minutes after the scheduled time. 3. [...]

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, in that: 1. There was a bag of shredded cheese past its use-by date in the reach-in cooler. 2. There were cleaning supplies in the dry storage room. 3. There was a bag of breadcrumbs that was opened, unsealed, without a label and use-by date in the dry storage room. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observations, interviews, and record reviews, 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 4 of 6 residents (Residents #5, #9, #10 and, #32) reviewed for infection control, in that: 1. Medication Aide D did not sanitize the Blood pressure cuff between Residents. 2. CNA B did not use the proper technique to sanitize her hands while providing incontinent care for Resident #10. 3. LVN E touched Resident #32's bed table and did not sanitize her hands prior to providing care. These deficient practices could place residents at-risk for infection due to improper care practices.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' right to request, refuse, and/or discontinue treatment and to formulate an advance directive for 1 (Resident #9) of 14 residents reviewed for advance directives, in that: Resident #9 was unable to make her wishes of being full code known and, her OOH-DNR was executed by her family member without her consent or knowledge. This deficient practice put residents at risk of not having their rights honored when they stop breathing and there is no pulse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents have a right to personal privacy for 2 of 6 resident (Residents #10 and #25) reviewed for privacy, in that: 1. CNA A and CNA B did not close completely Resident #10's privacy curtain while providing incontinent care. 2. LVN C left her computer screen open showing Resident #25's protected information while administering medications. This deficient practice could place residents at-risk of loss of dignity due to lack of privacy.

Inspectors wroteBased on observation, interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident for 1 of 14 residents (Resident #39) whose assessments were reviewed, in that: The facility failed to ensure that Resident #39's care plan correctly noted the resident's exit seeking behavior in his care plan. This deficient practice could lead to improper identification of residents with elopement tendencies resulting in potential harm.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received proper treatment and care to maintain mobility and good foot health for 1 of 1 resident (Resident #9) reviewed for foot care. The facility failed to provide Resident #9 with access to podiatry care. This deficient practice placed residents at risk of discomfort, poor foot hygiene, and a decline in residents' physical condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident environment remains as free of accident hazards as is possible for 1 of 3 halls (Hall 300) observed for accidents and hazards, in that: The facility failed to ensure potential hazards were locked up in Hall 300 This deficient practice could place residents at risk of a diminished quality of life due to an unsafe environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure all drugs and biological were stored in locked compartments for 1 of 3 medication carts (Hall 300 Medication Cart) reviewed for storage, in that: During medications administration, LVN C left Hall 300 Medication cart unlocked on 1 occasion. This deficient practice could place residents at risk of misappropriation of medications or harm due to accidental ingestion of unprescribed mediations.

Inspectors wroteBased on interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 2 residents (Resident #42) reviewed for hospice services, in that: The facility did not have Resident #42's most recent Physician Certification of Terminal Illness. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who is unable to carry out activities of daily living receives the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 3 of 16 residents (Residents #15, #35, and #43) reviewed for ADL's. 1. Resident #15 did not receive his scheduled showers. 2. Resident #35 did not receive her scheduled showers. 3. Resident #43 did not receive his scheduled showers. This failure could place residents at risk of not receiving the care they require to maintain their highest practical well-being, and could result in low self-esteem, anxiety, embarrassment, and a decline in their quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure licensed nurses have the specific competencies and skill sets necessary to care for residents' needs, as identified through resident assessments, and described in the plan of care to include but not limited to assessing, evaluating, planning, and implementing resident care plans and responding to resident's needs for 1 of 5 facility nurses (GVN) evaluated for licensed nurses. The facility failed to ensure the GVN (Graduate Vocational Nurse) did not continue to work as a GVN after her permit to practice was expired from [DATE] to [DATE]. This failure could place residents at risk of not receiving appropriate care and services to meet their needs by qualified, competent nurses.

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 and failed to designate a registered nurse to serve as the director of nursing on a full-time basis for 1 of 1 facility reviewed for nursing services. 1. The facility failed to designate a full time DON from 4/4/23 to 4/21/23. 2. The facility failed to use the services of an RN as required for 9 days. This could result in resident's not receiving the needed care and services to meet their needs and could result in illness, a decline in health, and in quality of care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect and promote the residents' right to a dignified existence for 1 of 16 residents (Resident #15) reviewed for dignity, in that: Resident #15's wheelchair was soiled and in disrepair. This deficient practice could lead to diminished self-esteem and quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete an accurate assessment of each resident's functional capacity for 1 of 16 residents (Resident #35) whose assessments were reviewed, in that: The facility failed to ensure that Resident #35's MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life or an inability to eat regular texture foods.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete an accurate assessment of each resident's functional capacity for 1 of 16 residents (Resident #35) whose assessments were reviewed, in that: The facility failed to ensure that Resident #35's MDS assessment correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life due to an inability to eat regular texture foods.

Inspectors wroteBased on observation, interview, and record review the facility failed to complete an accurate assessment of each resident's functional capacity for 1 of 16 residents (Resident #35) whose assessments were reviewed, in that: The facility failed to ensure that Resident #35's care plan correctly noted the resident's lack of natural teeth, tooth fragments, and/or dentures. This deficient practice could lead to diminished quality of life due to an inability to eat regular texture foods.

Inspectors wroteBased on observation and interview, the facility failed to assure drugs and biologicals were secured properly in 1 of 2 nurses' stations (Station 1) observed, in that: Three unsecured medications were found inside Resident #35's clinical record binder at nursing station #1. This deficient practice could place residents at-risk for harm due to ingesting medications not prescribed to them, and possible drug diversion.

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 facility kitchen, in that: 1. Individual packets of whipped spread were not refrigerated and not placed in an ice bath during preparation for the breakfast meal. 2. The top and sides of the dish sanitizing unit were soiled with a substance resembling sand. These deficient practices could lead to diminished quality of life due to foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to collaborate with hospice representatives and coordinate the hospice care planning process for each resident receiving hospice services, to ensure quality of care for the resident, ensuring communication with the hospice medical director, the resident's attending physician, and others participating in the provision of care for 1 of 3 resident (Resident #33) reviewed for hospice services, in that: The facility did not have Resident #33's most recent hospice Plan of Care, Hospice Consent and Election Form, and Physician Certification of Terminal Illness. This deficient practice could place residents who receive hospice services at-risk of receiving inadequate end-of-life care due to a lack of documentation, coordination of care and communication of resident needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 public restroom on the 300 Hall, in that: The public restroom utilized by residents, staff, and visitors on the facility's 300 Hall had a sink which was loosely affixed to the wall, a toilet with stained and missing caulking and loosely affixed to the floor, dark gray and black stains in the toilet, and a stained washcloth on the floor. This deficient practice could lead to residents living in, staff working in, and residents visiting in an environment that is not safe, functional, sanitary, and comfortable.