Avir at Grand Saline

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents were free from physical abuse for 2 of 10 residents reviewed for abuse. (Residents #2 and #3)The facility failed to ensure Resident #3 was free from physical abuse when Resident #2 punched Resident #3 in the left eye, resulting in bruising and a black eye. This failure could place residents at risk for physical abuse, mental abuse, emotional abuse, and harm.

Inspectors wroteBased on interview, and record review, the facility failed to ensure residents with dementia received appropriate treatment and services to maintain their highest practicable well-being for 2 of 10 residents reviewed for dementia care. (Resident #'s 2 and 3) The facility failed to identify and address the causes and triggers of Resident #2's behaviors and failed to implement effective, individualized dementia-care interventions, resulting in Resident #2 punching Resident #3 in the eye on July 10, 2026, causing bruising and blackened discoloration. This failure could place residents with dementia at risk for increased behaviors and decreased quality of life.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide pharmaceutical services including procedures to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs to meet the needs of each resident for 1 of 5 residents reviewed for pharmaceutical services. (Resident #1) The facility failed to ensure Resident #1's Lomotil was filled and available for administration from July 10 through July 13, 2026. Resident #1 missed 14 scheduled doses of Lomotil. The facility failed to ensure Resident #1's Lomotil prescription card was noted to have a direction change from scheduled to as needed. These failures could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observation, interview and record review the facility failed to report to state agency emergency situations that pose a threat to resident health and safety immediately, but not later than 24 hours after the incident occurs or is suspected for 1 of 1 kitchen reviewed for environmental safety. The facility failed to report an emergency situation involving a suspected gas leak/propane odor and fire department intervention to the State Agency within 24 hours of occurrence or discovery on 06/01/26. The fire department responded to the facility, investigated the reported propane odor, and shut off the propane supply to the oven. This failure could affect the health and safety of residents, staff, and visitors due to exposure to a hazardous environmental condition within the facility. [...]

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 in 1 of 1 kitchen reviewed for kitchen sanitation and safety.-The facility failed to ensure the required cooking and holding temperatures were known and followed.-The facility failed to ensure food temperatures were consistently monitored and documented for March 2026.-The facility failed to ensure the DM provided oversight and verification of food safety practices. These failures could affect the residents who received their meals from the facility's only kitchen, by placing them at risk for food-borne illness, and food contamination.

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 facility kitchens. The facility failed to ensure the reach-in stainless steel freezers and coolers were free from food debris, dried liquid splatters and fingerprints. The facility failed to ensure the bulk bins for sugar, flour and cornmeal were kept clean. The facility failed to ensure the outside of the milk box was clean. The facility failed to ensure the areas above the ovens on the stove were kept clean. The facility failed to ensure the vent hood above the deep fryer was kept clean. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for 4 of 10 residents (Residents #64, #9, #20, and #47) reviewed for resident assessments. 1. The facility failed to ensure the accuracy of the PASRR Level 1 screening dated 9/15/25 for Resident #64. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Delusional Disorder) was present on 3/22/24. 2. The facility failed to ensure the accuracy of the PASRR Level 1 screening dated 9/11/25 for Resident #9. The PASRR Level 1 screening did not indicate a diagnosis of mental illness, although the diagnosis (Delusional Disorder) was present at the time.3. The facility failed to ensure the accuracy of the PASRR Level 1 screening for Resident #20. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities, designed to meet the interests of and support the physical, mental, and psychosocial well-being for residents 1 of 2 units (secure unit) reviewed for quality of life, in that: The facility failed to ensure there were organized activities available to secured unit residents on 02/02/26. The facility failed to ensure the activities calendar was initially posted for February, 2026, and once it was posted, was followed. This failure placed residents at risk for a diminished quality of life, behaviors, isolation, and lack of stimulation.

Inspectors wroteBased on observations, 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 each resident for 2 of 4 medication carts (Cart Hall 2 and Cart Halls 1 & 3) reviewed for pharmacy services. The facility failed to ensure the nursing staff responsible for the safekeeping of narcotics performed and documented change of shift narcotic counts on multiple shifts and days for Medication Cart Hall 2 and Cart Halls 1 & 3. This failure could place residents at risk for loss of medications and possible drug diversion.

Inspectors wroteBased on interviews and record review, the facility failed to notify the resident's representative when there was a decision to transfer the resident from the facility to the hospital resident for 1 of 6 residents (Resident #95) reviewed for resident rights. The facility failed to notify Resident #95's representative when he was sent to the hospital emergency room for a change in condition. This failure could result in the family or guardian not being aware of conditions that may require them to make medical decisions.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the activities program was directed by a qualified professional who was a qualified therapeutic recreation specialist or an activity professional for 1 of 1 facility reviewed for quality of life. The facility did not have a qualified Activities Professional to direct their activities program. This deficient practice could affect any resident and could result in residents not receiving activities that were individualized to match the skills, abilities, and interests/preferences of each resident.

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 and infections for 1 of 5 residents (Residents #2) reviewed for infection control and prevention. The facility failed to ensure CNA G and CNA H donned (put on) appropriate PPE (a gown) prior to preparing Resident #2 for a transfer using a Hoyer lift and adjusting his urinary catheter drainage collection bag. This failure could place residents under their care at risk for the transmission of communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents reviewed for accidents. (Resident #1). The facility did not prevent Resident #1, who was wearing a Wanderguard bracelet, from leaving the facility unsupervised on 09/07/2025. Resident #1 was found at the intersection of the county road the facility resided on and a state farm to market road approximately 1.3 miles from the facility. The facility was not aware the resident was missing for approximately 1 hour. The noncompliance was identified as PNC. The IJ began on 09/07/2025 and ended on 09/09/2025. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of potential accidents, injuries, harm, or death.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission that included the instructions needed to provide effective and person-centered care of the resident that meets professional standards of quality care for 3 of 4 residents (Residents #2, #3, #4) reviewed for baseline care plans. The facility failed to ensure Resident #2's and Resident #4's baseline care plans were implemented and made available to nursing staff within 48 hours of admission. The facility failed to ensure Resident #3's baseline care plan included instructions to address the principal diagnosis of COPD. The facility failed to ensure Resident #3's baseline care plan included instructions to address identified risks for hyperglycemia and hypoglycemia. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident #3) and her representative were informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment alternatives or treatment options and to choose the alternative or option he or she prefers. The facility failed to inform Resident #3 and her responsible party in advance about changes made to the physician orders involving insulin dosing and monitoring of blood sugar levels. This failure could place residents at risk of not being informed of changes to their treatment plan and the opportunity to direct his or her own medical treatment.

Inspectors wroteBased on interview and record review, the facility failed to ensure 1 of 3 residents (Resident #3) and representative was informed of her right to participate in the development and implementation of a person-centered plan of care. The facility failed to facilitate the inclusion of Resident #3 and/or the representative in the care planning process. This failure could prevent residents from incorporating their personal and cultural preferences in developing goals of care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a comprehensive assessment was completed, using the CMS-specified process, within the regulatory time frames for 1 of 3 residents (Resident #4) reviewed for comprehensive assessments. The facility failed to complete a comprehensive MDS assessment for Resident #4 within 14 days of admission to the facility. This failure could place new residents at risk of delays in assessments and the residents' care plans not accurately reflecting their current needs.

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 set forth 483.10(c)(3, that includes measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment for 1 of 3 residents (Resident #2) reviewed for comprehensive assessments. The facility failed to ensure a comprehensive person-centered care plan was developed and completed within 21 days of admission to the facility for Resident #2. This failure could place residents at risk of a delay in receiving care and services to meet medical and nursing needs.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation or mistreatment, including injuries of unknown source and misappropriation of resident property, are reported immediately, but , but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 2 of 6 (Resident # 4 and Resident #5) residents reviewed for abuse and neglect. The facility staff did not report to the state agency Resident #4's complaint of physical abuse by CNA J and CNA K on 2/17/25. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure the necessary treatment and services, in accordance with comprehensive assessment and professional standards of practice, to prevent development of pressure injuries was provided for 1 of 4 (Resident #1) residents reviewed for pressure injuries. The facility failed to ensure Resident #1 did not develop a DTI to her right heel. These failures could place residents at risk for development of pressure ulcers, worsening of existing pressure injuries, infection, pain, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 5 staff (CNA F and CNA G) viewed for infection control. The facility failed to ensure the CNA F performed hand hygiene between glove changes while performing incontinent care on Resident #2. The facility failed to ensure CNA G changed gloves and performed hand hygiene after taking a dirty wipe from CNA H and handing her a clean wipe during incontinent care for Resident #3. These failures could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include : 1. During an observation on 5/8/25 at 9:57 a.m. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions for 1 of 1 facility kitchens. 1. The facility failed to ensure scoops were not left in the flour in the bulk flour bin. 2. The facility failed to ensure a box of raw cabbage was not stored on the floor in front of the reach in cooler. 3. The facility failed to ensure food items were labeled or dated. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

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 and infections for 4 of 12 residents (Residents #18, #20, #58, #60) reviewed for infection control. 1. The facility failed to ensure LVN A wore the appropriate PPE while administering medications to Resident #18 who required EBP. 2. The facility failed to provide appropriate containers to dispose of contaminated PPE for Residents #20, #58, and #60 who required contact isolation. These failures could place residents at risk for cross-contamination and the spread of communicable diseases and infections.

Inspectors wroteBases on observations, interviews and record reviews, the facility failed to have sufficient nursing staff with the appropriate competencies and skill sets to provide nursing and related services to assure resident safety and attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident for 1 of 2 staff (LVN A) reviewed for nursing services. LVN A did not don a gown prior to administering Resident #18's medications, who was on enhanced barrier precautions (EBP). The facility did not ensure LVN A received initial EBP training upon hire. These failures placed could place residents at risk for cross-contamination and the spread of communicable diseases and infections.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to implement infection control practices designed to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable diseases and infections for 3 of 4 residents (Residents #54, #3, and #27) reviewed for infection control practices. LVN B failed to sanitize the glucometer (instrument used for point-of care blood glucose testing) between 3 residents (Residents #54, #3, and #27) during medication administration. LVN B failed to utilize proper hand hygiene during point-of-care testing using a glucometer and insulin administration for 3 residents (Residents #54, #3, and #27). These failures placed the residents under her care at risk for exposure to possible transmission of communicable diseases and infections.