Avir at Grapevine

Inspectors wroteBased on interview and record review, the facility failed to use the services of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 12 of 74 days (01/12/25, 01/25/25, 01/26/25, 02/22/25, 02/23/25, 03/01/25, 03/02/25, 03/08/25, 03/09/25, 03/15/25, 03/16/25, and 05/18/25) reviewed during a look back period from 01/01/25 to 09/14/25 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 01/12/25, 01/25/25, 01/26/25, 02/22/25, 02/23/25, 03/01/25, 03/02/25, 03/08/25, 03/09/25, 03/15/25, 03/16/25, and 05/18/25. This failure could place residents at risk of not having their nursing and medical needs met and improper care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for two of three staff LVN B and MA E which resulted in a 17.95% medication error rate after 39 opportunities with 7 errors for three of five residents (Residents#4, #10 and #59) observed for medication pass. 1. The facility failed to ensure MA E administered the correct eye drop for Resident #59 at 07:46 AM. 2. The facility failed to ensure MA E administered Dextromethorphan-Guaifenesin Oral Tablet 20-400 MG (Dextromethorphan-Guaifenesin) Give 1 tablet by mouth every 12 hours for cough for Resident #4 at 07:46 AM. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure drugs and biologicals used in the facility were labeled with currently accepted professional principles, and included the appropriate accessory and cautionary instructions, and the expiration date when applicable for 1 of 3 medication carts (Nurses' medication cart for Hall 200) reviewed for medication storage. The facility failed to ensure the nurses' medication cart for 200 halls did not contain medications that were expired. This failure could place residents at risk of adverse medication reactions.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a private meeting space for the residents' monthly council meetings for 7 of 7 confidential residents reviewed for resident council. The facility failed to provide a private space for resident council meetings. This failure could place residents, who attended resident council meetings, at risk of not being able to voice concerns due to a lack of privacy.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for 1 of 16 residents (Resident #16) reviewed for comprehensive care plans. The facility failed to develop a comprehensive care plan addressing weight loss for Resident #16. This failure could place residents at risk of not having their individual needs met and not receiving necessary care and services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to revise and review the care plan for 1 of 5 residents (Resident #10) reviewed for comprehensive care plans timing and revision. The facility failed to revise and review Resident #10's care plan to include his physician orders to have a 70 ml water flush during his tube feedings. This failure could lead to the residents not receiving appropriate hydration intake.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide care and services in accordance with subsection (a) of this section for the following activities of daily living, hygiene (grooming) for 1 of 5 residents (Resident #67) reviewed for ADL care. The facility failed to provide Resident #67 assistance with nail care. Resident #67 nails were observed to be about half inch long with black debris under nails on both hands. This failure could place the residents at risk for decreased feelings of self-worth and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents receive treatment and care in accordance with professional standards of practice, based upon the comprehensive person-centered care plan and the residents' choices for 1 of 3 residents (Residents #52) reviewed for wounds. The facility failed to follow physician orders for the treatment of the surgical wound on Resident #52's left foot, to include failing to properly wrap the foot and ensure the nurses initialed and dated the dressing. This failure could place residents at risk of not receiving the care and services to meet their needs.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure a resident who is fed by enteral means receives the appropriate treatment and services to prevent complications of enteral feeding for 1 of 1 resident (Resident #10) reviewed for tube feeding management. The facility failed to label and date Resident #10's tube feeding formula and water bags to indicate when the feeding was started. This failure could place residents receiving tube feedings at risk of gastrointestinal disturbances (relating to the stomach and the intestines), and bacterial infection.

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 2 residents (Residents #4 and #52) reviewed for infection control during medication administration. MA E failed to disinfect the blood pressure cuff in between blood pressure checks for Resident #4 and Resident #52. These failures could place residents at risk of cross-contamination which could result in infections or illness.

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 the facility's one and only kitchen reviewed for food and nutrition services. The facility failed to ensure the four steamtable compartments in the kitchen were clean and free of debris before food was placed in them. This failure could affect 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 ensure the menus were followed for 1 (the lunch meal on 07/09/25) of 1 meal reviewed for food and nutrition services. The facility did not serve the posted lunch menu of cornbread and seasoned okra. This failure could affect all residents in the facility, who eat from the kitchen, by placing them at risk of not knowing what was going to be served for that meal.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services including procedures that assure the accurate dispensing and administering of all drugs and biologicals to meet the needs of each resident for 1 of 1 resident (Resident #1) reviewed for pharmaceutical services. The facility failed to ensure MAs and nurses were following physician orders for administering Resident #1's Lidocaine Patch 4%, which was used for preventing pain, on 05/04/25. This failure could put residents at risk of not receiving their medications as ordered.

Inspectors wroteBased on interview and record review, the facility failed to ensure personnel provided basic life support, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 8 residents (Resident #11) reviewed for CPR. LVN A failed to initiate CPR when Resident #11 did not have a State recognized advance directive which meant the resident was a Full Code status, and he was found on the floor on the fall mat with his face noted to be reddish purple, weak pulse with no obvious respirations or breathing patterns noted. An Immediate Jeopardy (IJ) was identified on [DATE]. The IJ template was provided to the facility on [DATE] at 4:45 PM. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #6) reviewed for abuse. The facility failed to ensure Resident #6 had the right to be free from abuse when Resident #7 pushed her on 01/21/25, causing Resident #6 to fall which resulted in a pelvic fracture. An IJ was identified on 03/12/25. The IJ template was provided to the facility on [DATE] at 4:51 PM. While the IJ was removed on 03/13/25, the facility remained out of compliance at a scope of isolated and a severity level of potential for more than minimal harm because the facility was continuing to monitor the implementation and effectiveness of their Plan of Removal. This failure placed residents at risk for abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents for 5 of 40 residents (Residents #3, #5, #8, #9, and #10) and one unit reviewed for a clean environment. 1. The facility failed to keep the Memory Care Unit was free of offensive odors. 2. The facility failed to ensure Residents #3, #5, #8, #9, and #10 rooms were kept in a sanitary and comfortable manner. This failure could place the residents at risk of exposure to infectious material and decreased feelings of self-worth.

Inspectors wroteBased on interview and record review, the facility failed to ensure the right to be free from misappropriation of property for 1 of 8 residents (Resident #12) reviewed for misappropriation of property. The facility failed to prevent the misappropriation of Resident #12's debit card when it was taken by CNA I. The noncompliance was identified as past noncompliance. The noncompliance began on 09/18/24 and ended on 09/18/24. The facility had corrected the noncompliance before the abbreviated survey began. This failure could place residents at risk of misappropriation of property.

Inspectors wroteBased on observation, interview, and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse and misappropriation for 1 of 2 incidents (Resident #6) reviewed for reporting. 1. The facility failed to implement its policy by ensuring LVN Z and CNA V reported an incident of resident-to-resident abuse immediately to the Administrator, who was the Abuse Coordinator, on 01/21/25 when Resident #7 pushed Resident #6, causing her to fall and sustain a pelvic fracture. 2. The Administrator failed to investigate an incident of abuse when Resident #6 was pushed by Resident #7 on 01/21/25 and sustained a pelvic fracture. 3. The Administrator failed to report to HHSC when Resident #7 pushed Resident #6 causing Resident #6 to sustain a pelvic fracture. This failure could place the residents in the facility at risk of continued abuse.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse were immediately report, but not later than 2 hours after the allegation is made, if the events that cause the allegation involve abuse or result in serious bodily injury, to the Administrator of the facility and to other officials including the State Survey Agency (HHSC) in a timely manner for 1 of 3 residents (Resident #6) reviewed for abuse. 1. LVN Z and CNA V failed to report an incident of resident-to-resident abuse immediately to the Administrator, who was the Abuse Coordinator, on 01/21/25 when Resident #7 pushed Resident #6, causing her to fall and sustain a pelvic fracture. 2. The Administrator failed to report to HHSC within 2 hours of Resident #6 being pushed by Resident #6 causing her to sustain a pelvic fracture. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to investigate and report an allegation of abuse for 1 of 3 residents (Resident #6) reviewed for abuse allegations. The Administrator failed to investigate an incident of abuse when Resident #6 was pushed by Resident #7 on 01/21/25 and sustained a pelvic fracture. This failure could place residents at risk of harm and injuries related to abuse and a delay in investigating.

Inspectors wroteBased on observation, interview, and record review, the facility failed to equip rooms to assure full visual privacy for each resident for 4 of 20 residents (Residents #1, #2, #3, and #4) reviewed for privacy curtains. The facility failed to ensure Residents #1, #2, #3, and #4 had full visual privacy. This failure could place residents at risk of exposure while care was being provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 5 of 40 residents (Residents #3, #5, #8, #9, and #10) reviewed for effective pest control. The facility failed to ensure Residents #3, #5, #8, #9, and #10 rooms were free of pests. These failures could place residents at risk of exposure to bugs and bug bites.

Inspectors wroteBased on observation, interview, and record review, the facility failed to treat each resident with respect, dignity, and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life for 2 (Residents #22 and #47) of 3 residents reviewed for dignity. RN D failed to maintain Resident #22 and #47's dignity and respect by standing between the residents while feeding both of them during lunch time on 08/27/24 at 12:17 PM . The failure could negatively affect the mental and psychological well-being of all residents who required the assistance of staff with eating.

Inspectors wroteBased on interview and record review, the facility failed to use the service of a Registered Nurse (RN) for at least eight consecutive hours a day, seven days a week for 5 of 30 days (05/25/2024, 05/26/2024, 06/01/2024, 06/08/2024, and 06/15/2024) reviewed during a look back period from 05/25/2024 to 08/25/2024 for weekend coverage. The facility failed to have RN coverage in the facility for eight consecutive hours on 05/25/2024, 05/26/2024, 06/01/2024, 06/08/2024, and 06/15/2024. This failure could place residents at risk for not having their nursing and medical needs met and improper care.

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 safety for 1 of 1 kitchen and 1 of 1 steamtable reviewed for kitchen sanitation, in that: Cook A placed food containers, of the lunch meal in a steamtable that contained contaminated tinted water and burnt food particles floating in it on 08/28/2024. This failure could place residents at risk for food contamination and foodborne illness.

Inspectors wroteBased on interview and record review, the facility failed to ensure the residents' rights to formulate an advance directive for 1 of 18 residents (Resident #239) reviewed for advanced directives. The facility failed to ensure Resident #239's code status (advance directives) was accurate and consistent with all records at the facility and did not provide information to the resident related to her right to formulate an advance directive. This failure placed residents at risk of not having their end of life wishes honored.

Inspectors wroteBased on interview and record review, the facility failed to assess a resident using the quarterly review instrument specified by the State and approved by CMS not less frequently than once every three months for 1 of 5 (Resident #80) residents reviewed for MDS assessments. The facility failed to complete Resident #80's Quarterly MDS Assessment within three months of their most recent comprehensive assessment. This failure could lead to residents not receiving care required for their individualized 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 as set forth at 483.10(c) and 483.10(c)3, that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment for one of eight residents (Resident #239) for care plan revisions, in that: The facility failed to develop a care plan addressing Resident #239's elected code status or advance directive. These failures could place residents at risk of receiving inappropriate care.

Inspectors wroteBased on interview and record review, the facility failed to ensure a final summary of the resident's status at the time of the discharge was available for release to authorized persons and agencies, with consent of the resident or resident's representative for 1 of 3 residents (Resident #87) reviewed for discharge summary. The facility failed to complete a discharge summary after Resident #87 left the facility and did not return. This failure could place residents at risk for a lack of continued care and services.

Inspectors wroteBased on observation, interview and record review, 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 1 (medication cabinet in the central supplies unit) and one refrigerator in the medication room for 100 and 200 halls reviewed for pharmacy services. The facility failed to ensure expired influenza vaccine, with an expiration date of 05/10/2024, in the Hall 100/200 Medication Room refrigerator and expired medications in the Central Supply medication cabinet were removed and destroyed on 08/28/2024 at 10:45 AM. The failure placed residents at risk of receiving medications that were ineffective due to having expired.

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 1 (Residents #2) of 2 residents reviewed for infection control. LVN L failed to put on a gown before entering Resident #2's room to administer a bolus feeding and medications to Resident #2, who was on enhanced barrier precautions. This failure placed residents at risk of cross contamination and the spread of infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices based on the comprehensive assessment of residents for three of six residents (Residents #1, #2, and #3) reviewed for wound care. The facility failed to follow physician orders for wound care for Residents #1, #2, and #3. The failure placed residents at risk of wound deterioration and infection.

Inspectors wroteBased on observation, interview and record review, the facility failed to immediately consult with the resident's physician when there was a change in the resident's condition or a need to alter treatment for one (Resident #1) of three residents reviewed for physician consultation. LVN A failed to consult with the physician for Resident #1 when the resident had a change of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which reflected the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment. An Immediate Jeopardy (IJ) situation was identified on 0719/24. [...]

Inspectors wroteBased on observation, interview, and record review, 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 three residents reviewed for quality of care. LVN A failed to ensure Resident #1 was provided with timely treatment when the resident had a changed of condition on 06/15/24. Resident #1 displayed signs and symptoms of pain when her left leg was touched on 06/15/24 at 7:45 PM. The physician was not notified the resident had a change of condition until the next morning 06/16/24 at approximately 6:00 AM and ordered x-rays, which revealed the resident had a left hip fracture, and she was sent to the hospital for evaluation and treatment. An Immediate Jeopardy (IJ) situation was identified on 0719/24. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide pharmaceutical services to ensure the accurate acquiring, receiving, dispensing, administering for one (Resident #1) of five residents reviewed for pharmacy services in that: LVN A failed to follow physician's orders for the administration of the medication lorazepam (an anti-anxiety medication) and hydrocodone (a pain medication) to Resident #1 on 09/04/23. This failure could affect residents and place them at risk of not receiving medications as ordered by their physician.

Inspectors wroteBased on interview and record review, the facility failed to ensure the clinical record were maintained in accordance with accepted professional standards and practices and were complete and accurately documented for one (Resident #1) of five residents records reviewed for resident records, in that: LVN A failed to accurately document the administration of Resident #1's hydrocodone and lorazepam on 09/04/23 on the resident's MAR. This failure could affect the residents medical record not being an accurate representation of the resident's medical condition or medical needs.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, comfortable, and homelike environment, for daily living for two residents (Resident #24 and Resident #5) of eighteen residents reviewed for environmental concerns. 1. Resident #24's and Resident #5's room had a foul odor, the floor was sticky with debris, and the toilet was covered in feces. The two residents shared a room. 2. There was a pervasive foul odor on the Memory Care Unit (300 Hall). These failures could place residents at risk of living with unclean, uncomfortable, un-homelike rooms and a diminished quality of life.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure total privacy for residents in 6 (Rooms 303 A bed, 304 B bed, 306 A bed, 307 A bed, 308 B bed and 309 A bed) of 19 rooms reviewed for privacy. The facility failed to provide curtains to ensure resident's privacy in Rooms 303 A bed, 304 B bed, 306 A bed, 307 A bed, 308 B bed and 309 A bed. This failure could place residents at risk of decreased self-worth by being exposed during resident care.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for one (Resident #32) of two residents reviewed for pressure ulcers. The facility failed to ensure the Stage 4 pressure ulcer on Resident #32's sacrum was covered with a dressing as ordered by the physician. This failure could affect the residents, who received pressure ulcer care, by placing them at risk for contamination of their wounds and causing unnecessary infections and worsening of pressure ulcers.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure it was free of a medication error rate of five percent (5%) or greater on 3 errors of 33 opportunities for errors leading to 9.09% medication error rates for one (LVN B) of two staff observed for medication pass. The facility failed to ensure LVN B administered all the crushed medication in the medication cups without leaving residue for Resident #2. These failures resulted in a 9.09% medication error rate and could put residents at risk who received medications via g-tube for not receiving the correct dose of medication and getting intended therapy.