Avir at Hillsboro

Inspectors wroteBased on interviews and record review the facility failed to ensure professional staff were licensed, certified, or registered in accordance with applicable State laws for 1 (CNA A) of 3 CNA's reviewed for proficiency of nurse aides. The facility failed to ensure CNA A had an active CNA license before allowing her to perform CNA tasks, working a total of 83.88 hours between [DATE] and [DATE], with an expired CNA license. This deficient practice had the potential to affect all residents in the facility who CNA A worked with when CNA A failed to maintain a current nurse aide certification.

Inspectors wroteBased on observation, interviews, and record reviews the facility failed to ensure personal privacy for 1 of 6 residents (Resident #1) reviewed for privacy while receiving care. 1. The facility failed to ensure the privacy of Resident #1 by not closing the door or pulling the privacy curtain during perineal care. This failure could place residents at risk of loss of privacy and dignity.

Inspectors wroteBased on observations, interviews, and record reviews , the facility failed to ensure no more than 14 hours between a substantial evening meal and breakfast the following day, except when a nourishing snack is served at bedtime, up to 16 hours may elapse between a substantial evening meal and breakfast the following day if a resident group agrees to this meal span for 61 of 61 residents reviewed for meal frequency . The facility failed to ensure the timing/hours between the supper and breakfast meal was no more than 14 hours. The current schedule was for 14.25 hours between dinner and breakfast the following day. This failure could place all 61 residents who received meals served from the facility's only kitchen at risk of decreased intake and meal dissatisfaction.

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 reviewed for sanitation. The facility failed to keep a clean veggie/dessert/drink freezer. This failure could place residents at risk of foodborne illness due to unhygienic food storage.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish procedures to ensure that enough water was available in the facility in the event of a loss of normal water supply for 1 of 1 facility. 1. The facility's emergency water supply consisted of 23 gallons (140, 16.9 fl oz water bottles and 1, 5-gallon jug) of water on hand for a census of 61 residents stored in the kitchen's pantry. 2. The facility failed to follow their water supply policy by not having enough water to service the facility's needs in case of a water outage. This failure could place residents at risk of not having water during an outage for bathing, cooking, and drinking.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to notify residents of how to file a grievance in an anonymous manner, for 6 confidential residents out of 6 residents interviewed for grievances. 1. The facility failed to notify Residents or their representatives either individually or through prominent postings throughout the facility on how to file a grievance or complaint in an anonymous manner. 2. The facility failed to ensure residents felt like they could complain about care without worrying someone would get back at them. These failures could affect resident's' ability to file a grievance without the fear of discrimination, reprisal, retribution, and their right to request a written decision regarding the resolution of their grievance. Findings Included: [...]

Inspectors wroteBased on record review, observations, and interviews, the facility failed to ensure the residents were free from abuse, misappropriation of resident property, and exploitation as defined in this subpart. This includes but is not limited to freedom from corporal punishment, involuntary seclusion and any physical or chemical restraint not required to treat the resident's medical symptoms for 3 of 6 residents (Resident #22, #25 and #45) reviewed for abuse. The facility failed to ensure that Resident #22 and Resident #45 were free from abuse when Resident #73 physically struck the residents on 11/21/2025. The facility failed to ensure Resident #25 and Resident #73 were free from abuse when Resident #25 and Resident #73 were found in Resident #25's room without their clothes on attempting to engage in a sexual act on 12/4/2025. [...]

Inspectors wroteBased on observation , interview, and record review, the facility failed to ensure each resident was provided with a nourishing, palatable, well-balanced diet that met his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 (Resident #39) of 24 and multiple confidential residents reviewed that received food from the facility kitchen. 1. The facility failed to provide Resident #39 with a meat sandwich on multiple occasions when she requested them, or an alternative to the posted meal, when her meal tickets had Meat portions for all meals printed on them. 2. The facility failed to have a variety of breakfast meals available to residents. This failure could place residents at risk of weight loss, dissatisfaction with meal service, and interfered with their desire to gain weight.

Inspectors wroteBased on record review and interviews, the facility failed to provide advance notice of change in services and charges not covered under Medicare for 1 of 3 residents (Residents #77) reviewed for Medicaid and Medicare Coverage Liability Notices. The facility failed to ensure Resident #77 was provided with a Notice of Medicare Non-coverage (NOMNC) when the resident discharged from Medicare Part A skilled services with benefit days remaining for that episode, or 2 days prior to the resident's planned discharge. This failure could place the residents, or their representatives, at risk of not being fully informed about services covered by Medicaid Part A and unknowingly being charged for skilled nursing services. Record review of Resident #77's admission record dated 12/6/2025, reflected a [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure they did not employ an individual who was found guilty of a criminal offense barring employment by a court of law for 1 of 6 (Maintenance Director) employees reviewed for abuse and neglect. The facility did not disqualify the Maintenance Director from working when a criminal history record indicated a criminal conviction barring employmen t of credit or debit card abuse elderly: 32:31 (D) Felony -3rd degree in a nursing facility. The Maintenance Director had worked in the facility from 09/19/2025 through 12/05/2025. This failure could place residents at risk for possible abuse, neglect, or exploitation.

Inspectors wroteBased on interviews and record review the facility failed to ensure the resident assessment accurately reflected the resident's status for 2 of 10 (Resident #52 and Resident #61) reviewed for accuracy of assessments. The facility failed to ensure Resident #52's Quarterly MDS assessment dated [DATE] was accurately coded for the use and indication of high-risk medications, specifically anticoagulant and antiplatelet medication. The facility failed to ensure Resident #61's Quarterly MDS assessment dated [DATE] was accurately coded for the use and indication of high-risk medications, specifically anticoagulant and antiplatelet medication. This failure could place residents at risk of not receiving the appropriate care, treatment, and services due to inaccurate assessments. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were unable to carry out activities of daily living received necessary services to maintain personal hygiene for one (Resident #15) of eight residents reviewed for bathing/showering. 1. The facility failed to provide showers to Resident #15 in compliance with his shower schedule.2. The facility failed to have appropriate interventions in place when Resident #15 refused or was in too much pain to receive a bath. This deficient practice could place residents at risk of decline in skin integrity and overall healthFindings included: Review of Resident #15's quarterly MDS assessment dated [DATE] reflected a [AGE] year-old male who admitted to the facility on [DATE]. His diagnoses included: [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, 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 of each resident, encouraging both independence and interaction in the community for 1 (Residents #4) of 8 residents reviewed for activities. The facility failed to ensure they provided in-room activities for Resident #4 who spent most of or all her time in her room. This failure placed residents at risk of boredom, depression, and diminished quality of life. [...]

Inspectors wroteBased on observations, interviews, and record reviews, 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 1 of 6 Residents (Resident #17) reviewed for respiratory care. The facility failed to place Resident #17's oxygen tubing in a bag when not in use and failed to keep her concentrator filter clean. This failure could place residents at risk of not receiving appropriate air flow resulting in shortness of breath respiratory infections.

Inspectors wroteBased on interview and record review , the facility failed to ensure residents' drug regimen was adequately monitored and free from unnecessary drugs for 1 of 6 (Resident #10) residents reviewed for pharmacy services. The facility failed to obtain a stop date for Resident #10's Amoxicillin-Pot Clavulanate (an antibiotic used to treat an acute infection) started on 11/27/2025. This failure could place residents at risk of side effects (gastrointestinal upset, multiple drug-resistant infections) related to long term antibiotic use.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an infection and prevention control program that included, at a minimum, a system for preventing and controlling infections for 3 of 6 residents reviewed for infection control (Resident #39, Resident #42, and Resident #57). 1) MA failed to clean the electronic blood pressure cuff after use on Resident #57 and prior to use on Resident #39 in an observation of medication pass at 8:45 a.m. on 12/4/25. 2) LVN A did not wear PPE for enhanced barrier precautions while performing wound care and wash/clean her hands when removing soiled gloves, prior to applying clean gloves on 12/04/2025 at 10:17 a.m. for Resident #42's wound care observation. This deficient practice could place residents at risk for cross contamination and the spread of infection.

Inspectors wroteAcronyms: HTN COPD MDS DON ADM LVN BIMS Based on interview, and record review the facility failed to develop and implement a comprehensive person-centered care plan within 7 days after comprehensive assessment and within 21 days from admission for 1 of 1 resident (Resident #1) reviewed for care plans. The facility failed to ensure Resident #1 had a Comprehensive Care Plan that was due within 21 days of admission to reflect the person-centered needs of Resident #1. Resident #1 received only a Baseline Care plan at the time of admission. This failure could place residents at risk of getting insufficient care and having personal needs not met. This could result in diminishing physical and psychosocial well-being.

Inspectors wroteAcronyms: HTN COPD MDS DON ADM LVN BIMS Based on observations, interviews, and record review the facility failed to ensure that the resident's record reflected an ongoing assessment of the resident's respiratory status, a practitioner's order, and indications for use of oxygen for 1 of 1 resident (Resident #1) reviewed for oxygen therapy. The facility failed to ensure Resident #1's chart reflected a practitioner's order for oxygen indicating the amount and flow type for Resident #1's use of oxygen. There was no oxygen assessments in the chart for Resident #1's diagnosis of COPD. This failure placed residents at risk of developing respiratory distress by receiving too much or too little oxygen .

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure based on the comprehensive assessment of a resident, 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. The facility failed to administer triamcinolone acetonide (a medication utilized for pain/itch relief) when Resident #1 was experiencing increased itching from 12/16/24 through 03/17/25. This failure could place residents at risk of not receiving medical care for conditions that cause stress and irritation, and significantly impact quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as possible for one (Resident #1) of four residents reviewed for accidents hazards, in that: The facility failed to ensure Resident #1 was transferred by mechanical device from her shower chair to her bed without receiving a cut and a bruise on her right toe. This failure could place residents at risk of pain, bruising, or skin tears.

Inspectors wroteBased on observation, interviews, 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 1 (Resident #1) of 6 residents reviewed for incidents. The facility failed to identify a purple bruise observed on Resident #1's forearm on 11/19/24. This deficient practice could place residents at risk of abuse, neglect, and untreated and unassessed injuries.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure the resident environment remained free of accident hazards as was possible for 1 of 1 doorway in the 100-hallway reviewed for accidents and hazards. The facility failed to ensure the storage room on the 100-hallway remained closed and locked while a staff member was not actively retrieving or stocking hazardous items in the storage room when the door to the storage room was observed open on 9/24/2024. This failure could place residents who accessed the 100- hallway at risk of injury or illness from access and exposure to hazardous items.

Inspectors wroteBased on observation, interview, and record review, 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 18 (Resident #1, #4, #5, #12, #14, #19, #20, #26, #33, #34, #40, #42, #53, #57 #58, #65, #72, and #122) of 24 residents reviewed for late medications. Facility failed to ensure Resident #1, #4, #5, #12, #14, #19, #20, #26, #33, #34, #40, #42, #53, #57 #58, #65, #72, and #122 were given medications at 9:00 AM in the morning and not administered after 11:00 AM on 09/25/24. These failures could place residents at risk for medication errors and jeopardize the resident health and safety.

Inspectors wroteBased on observation, interview, and record review, facility failed to ensure the medication error rate was not 5 percent (5%) or greater for total number of errors, 27 of 177 opportunities for errors, resulting in an 15% medication error rate for 16 of 24 residents observed for medication pass (Resident #1, #4, #5, #14, #19, #20, #22, #26, #34, #40, #42, #53, #57 #58, #65, and #122) per observation on 09/25/2024. Facility failed to ensure Resident #1, #4, #5, #14, #19, #20, #22, #26, #34, #40, #42, #53, #57 #58, #65, and #122 were given medications at 9:00 AM in the morning and not administered after 11:00 AM on 09/25/24, which resulted in medication errors. These failures could place residents at risk for significant medication errors and jeopardize the resident health and safety.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable for one of one regular diet test trays reviewed for food and nutrition services. The facility failed to properly cook rice, serving rice which had hard, uncooked bits. This failure could affect the residents who are provided daily meals by the facility, by placing them at risk for not enjoying meals, and weight loss.

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 infections for all residents in the memory care unit and for 4 residents on the 300 hallways (Residents #5, #12, #20, #34 and #38) reviewed for infection control. 1. The facility failed to ensure LVN H, CNA I, and CNA J performed hand hygiene while passing trays and setting up meals for all residents in the memory care unit on 09/24/2024. 2. The facility failed to ensure LVN H and CNA I performed hand hygiene before and after helping Resident #38 eat her lunch in the dining room on 09/24/2024. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pests for two of four halls and the food preparation area in the facility's only kitchen reviewed for physical environment. 1) The facility failed to effectively treat for the flies on hall 200 and hall 300. 2) The facility failed to implement preventative measures in the kitchen to prevent flies. These failures could place residents at risk for the potential spread of infection, cross-contamination, food-borne illness, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to promote care for residents in a manner and in an environment that maintained or enhanced dignity and respect for 1 (Resident #38) of 21 residents in memory care dining rooms in that: 1. The facility failed when on 09/24/2024 LVN H was standing while feeding (Resident #38) in the memory care unit dining room at lunch meal. 2. The facility failed when on 09/24/2024 CNA I was standing while feeding (Resident #38) in the memory care unit dining room at lunch meal. This deficient practice could affect residents who were dependent on eating and could contribute to feelings of poor self-esteem and decreased self-worth.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to review the risks and benefits of bed rails and enabler/grab bars (smaller bars used by the person in bed to reposition themselves), with the resident or resident representative, have physician orders, conduct a safety assessment, and obtain informed consent prior to installation for one (Resident #224) of three residents beds observed and reviewed for quarter bed rails/enabler bars. The facility failed to have evidence on 09/25/2024 of informed consent, assessment of the resident for risk of entrapment, care planning or a physician's order for the quarter bed rails/enabler bars for Resident #224. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that accommodated resident's preferences for one (Resident #40) of five residents reviewed for food and nutrition services. The facility failed to provide Resident #40 with his preferred food when they failed to provide toast for his breakfast, and provided pancakes instead. This failure could affect the residents who are provided daily meals by the facility, by placing them at risk for not enjoying meals, and weight loss.

Inspectors wroteBased on interview, and record review the facility failed to develop and implement written policies and procedures that prohibit and prevent abuse/neglect and investigate such allegations for 1 (Resident # 1) of 6, residents reviewed for accidents and supervision. The facility failed to investigate a serious injury that occurred when Resident # 1 sustained a wrist fracture and other injuries CNA A left her unsupervised and she fell out the bed on 4/14/2024. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 4/18/2024 at 6:07pm. The IJ Immediate Jeopardy template was provided to the ADM on 4/18/2024 at 6:07pm. While the (IJ) Immediate Jeopardy was removed on 4/19/2024 at 1:26pm, the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting. [...]

Inspectors wroteBased on interview, and record review the facility failed to thoroughly investigate the incident of how Resident #1 was left unsupervised and fell from the bed. There was no evidence to show the incident had been investigated at all. The facility failed to investigate a serious injury that occurred when Resident # 1 sustained a wrist fracture and other injuries CNA A left her unsupervised and she fell out the bed on 4/14/2024. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 4/18/2024 at 6:07pm. The IJ Immediate Jeopardy template was provided to the ADM on 4/18/2024 at 6:07pm. While the (IJ) Immediate Jeopardy was removed on 4/19/2024 at 1:26pm, the facility remained out of compliance at a scope of isolated and severity level of actual harm because all staff had not been trained on abuse/neglect, incident/accidents, and reporting. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure adequate supervision and assistive devices to prevent accidents for 1(Resident #1) of 6 residents reviewed for accidents and supervision. The facility failed to ensure on 4/14/2024 that Resident # 1 was repositioned in her bed by CNA A, who placed her too close to the edge of the bed. The lack of supervision resulted in that Resident # 1 fell out her bed and sustained a fractured right wrist, swollen right side of her face, and other scratches to her legs from the fall. Resident # 1's right wrist was placed in a brace, and she was prescribed pain medication as needed. This failure resulted in an identification of an (IJ) Immediate Jeopardy on 4/18/2024 at 6:07 p.m. The IJ Immediate Jeopardy template was provided to the ADM on 4/18/2024 at 6:07 p.m. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure all alleged violations were reported to HHSC for 1 (Resident # 1) of 6, residents reviewed for accidents and supervision. The facility failed to report to HHSC a serious injury that occurred. The facility failed to investigate a serious injury that occurred when Resident # 1 sustained a wrist fracture and other injuries CNA A left her unsupervised and she fell out the bed on 4/14/2024. The failure could place residents at risk of accidents and harm.

Inspectors wroteBased on observations, interviews, and record reviews the facility failed to ensure residents received services in the facility with reasonable accommodations of each resident's needs for 4 of 5 residents (Residents #1, #2, #3 & #4) reviewed for call lights in that: Residents #1, #2, #3, & #4's call lights were not within reach. This failure could affect all residents who needed assistance with activities of daily living and could result in needs not being met.

Inspectors wroteBased on interview and record review, the facility failed to immediately notify the resident's representative(s) when there was a significant change in the resident's physical status for one (Resident #1) of four residents reviewed for changes in condition. The facility failed to ensure Resident #1's POA was notified that he had a fall and was sent out to the local hospital for further evaluation. This failure placed residents at risk of a decreased quality of life and increased psychosocial harm by depriving residents of the right to have representative(s) notified of significant changes in resident condition.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' right to a safe, clean, comfortable, and homelike environment for one of four (secured unit) halls reviewed for environment. The secure unit of the facility possessed a strong foul odor. This failure placed residents at risk of discomfort and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to have sufficient nursing staff 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 one of four halls (hall 300/secure unit) reviewed for sufficient staff. The facility regularly had only one staff person working with the 20 residents in the 300 hall/secure unit. This failure placed residents at risk of falls, escalating aggressive behaviors, and diminished quality of life.

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 residents' rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, and mental, and psychosocial needs for 1 of 15 residents (Residents #20) reviewed for care plans. The facility failed to ensure Resident #20's care plan included his use of an O2 concentrator and a C-PAP machine. This failure could place residents at risk of receiving inadequate interventions that were not individualized to their care needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide respiratory care consistent with professional standards of practice for 2 of 2 residents (Resident #20 and Resident #42) reviewed for oxygen therapy. A) The facility failed to ensure Resident #20's C-PAP mask and tubing, O2 tubing, and oxygen concentrator filter were kept clean for his use. The humidifier bottle was empty. B) The facility failed to ensure Resident #42's O2 tubing was bagged and kept clean for her use. These failures could place all residents who use respiratory equipment at risk for respiratory infections.