Avir at Kaufman

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 1 of 3 staff (Treatment Nurse) observed for infection control. The facility failed to ensure the Treatment Nurse wore a gown when providing wound care to Resident #1. This failure could place residents and staff at risk for MDROs, cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include:1. [...]

Inspectors wroteBased on observations, interviews, 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 reviewed. The facility did not ensure:1. Food items were labeled and dated.2. The microwave was clean and free of food debris.3. The juice machine spigot was free from a red gooey substance where the juice was dispersed4. The cups, bowls and plate domes were stacked with water pooled between them. 5. The outside of the ice machine was clean. 6. Ice scoop holder was clean. 7. eggs were pasteurized.8. Drinks and food temps not taken after heating or reheating. 9. The Dietary Manager checked the chlorine level in the correct dishwasher cycle. These failures could place residents at risk for foodborne illness.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needed respiratory care was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the resident's goals and preferences for 4 of 5 residents (Residents #11, # 36, #27, and #15) reviewed for respiratory care. 1. The facility failed to ensure Resident #11's oxygen was set at 2 liters per nasal cannula as ordered on 12/18/25. 2. The facility failed to have Resident #36's oxygen sign outside the door and the oxygen tube dated on 01/05/26 and 01/06/26. 3. The facility failed to have Resident #27 and Resident #15's nebulizer dated or bagged on 01/05/26 and 01/06/26. This failure could place residents who receive respiratory care at risk of developing respiratory complications and a decreased quality of care.

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure all drugs were stored in a locked compartment, only accessible by authorized personnel for 3 of 3 residents (Residents #16, #15 and #41) reviewed for pharmacy services and 2 of 5 (100 and 200 Hall) medication carts reviewed for storage of medications. The facility to ensure: 1. Resident #15's Amlodipine (blood pressure medication), Potassium Chloride (medication to treat low levels of potassium) label from the pharmacy matched the orders placed in the electronic charting system and was free from medications at bedside. 2. Resident #16's Lorazepam (antianxiety medication) was secured behind two locks.3. Resident #41's Amlodipine label from the pharmacy matched the orders placed in the electronic charting system. 4. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide food that was palatable, attractive, and at a safe and appetizing temperature for 10 of 10 residents (Resident #32 and 9 confidential residents) reviewed for food and nutrition services. The facility failed to ensure dietary staff provided food that was palatable and had an appetizing temperature on 01/06/26. This failure could place residents at risk of decreased food intake, hunger, and unwanted weight loss.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 6 of 6 residents (Resident #'s 27, #36, #15, #9, #41 and #13) reviewed for infection control.1. The facility failed to ensure CNA K performed hand hygiene while providing incontinent care for Resident #27 on 01/06/26.2. The facility failed to ensure CNA N and CNA L wore PPE when providing care for Resident #36.3. The facility failed to ensure CNA G and CNA H performed hand hygiene while providing incontinent care for Resident #15 on 01/06/26.4. The facility did not ensure RN B performed hand hygiene prior to administering Resident #9's medications.5. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents had a right to personal privacy and confidentiality of medical records for 1 of 4 residents (Resident #15) reviewed for privacy and confidentiality. The facility did not ensure LVN A closed Resident #15's EMR before entering her room to administer her medications on 01/07/26. This failure could place residents at risk for low self-esteem, loss of dignity, and decreased quality of life due to medication administration record being accessible to others.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable environment for 1 of 10 residents (Resident #15) reviewed for a homelike environment. The facility failed to ensure Resident #15's room had wall trim in good repair. This failure could place residents at risk for an uncomfortable, unhomelike environment, and a diminished quality of life. Findings Included: During an observation on 01/05/2026 at 11:21 AM, Resident #15's room wall trim along the lower portion of the wall was lifting and jagged. The trim was observed to be uneven with sharp edges exposed. During an observation on 01/08/2026 at 8:17 AM, the damaged trim had been removed leaving the interior wall exposed. The exposed area was unfinished and did not have replacement trim or protective covering installed. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure individuals with mental health disorders were provided an accurate Preadmission Screening and Resident Review (PASRR) Screenings for 1 of 6 residents (Resident #36) reviewed for PASRR. The facility failed to ensure the correct PASRR (a preliminary assessment completed for all individuals before admission to a Medicaid-certified nursing facility to determine whether they might have a mental illness or intellectual disability) Level 1 Screening was submitted to the local authority for Residents #36, who had a diagnosis of mental illness upon admission. This failure could place residents at risk for a diminished quality of life and not receiving necessary care and services in accordance with individually assessed needs.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a baseline care plan within 48 hours of admission for 1 of 3 newly admitted residents reviewed. (Resident #53) The facility failed to develop a baseline care plan assessment for Resident #53. This failure could affect residents who are admitted to the facility with specialized needs and result in residents not receiving necessary care and services. Findings Included: During a record review on 01/08/2026 at 10:45 AM, the face sheet revealed Resident #53 was a [AGE] year-old male who admitted on [DATE] with the diagnoses of pneumonia (infection of the lungs). During a record review on 01/07/2026 at 9:30 AM, Resident #53's electronic medical record indicated the baseline care plan was not opened or initiated and remained highlighted in red with the due date (meaning past due). [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, which includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental needs, for 2 of 4 (Resident #11 and Resident #27) residents reviewed. The facility failed to care plan Resident #11's oxygen (which is vital for the human body as it is used by cells to produce energy) therapy. The facility failed to care plan Resident #27's nebulizer treatments (which uses a machine to turn liquid medicine into a fine mist, inhaled through a mask or mouthpiece, to deliver medication deep into the lungs for respiratory conditions). This failure could affect residents by placing them at risk of not receiving appropriate interventions to meet their current needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure each resident received adequate supervision to prevent accidents for 1 of 7 residents (Resident #17) reviewed for smoking-related accidents and hazards of 1 of 1 smoking areas. 1. The facility failed to ensure Resident #17 did not smoke near a grill with propane gas attached.2. The facility failed to ensure that no trash was in the red cigarette butts' canisters.3. The facility failed to ensure that no cigarette butts were on the ground or near the oxygen storage area. This failure could place residents at risk for injury.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents who were incontinent of bowel and bladder received appropriate treatment and services to prevent urinary infections for 1 of 2 residents (Resident #15) reviewed for incontinent care. The facility failed to ensure CNA G and CNA H properly cleaned the perineal/genital areas for Resident #15 during incontinent care. These failures could place residents at risk for urinary tract infections. During a record review of a face sheet dated 01/08/2026 indicated Resident #15 was a [AGE] year-old female who admitted on [DATE] and readmitted on [DATE] with the diagnosis of other cerebral infarction due to occlusion or stenosis of small artery (stoke because a small artery in the brain becomes blocked cutting off blood flow to a specific area of the brain). [...]

Inspectors wroteBased on interviews and record review, the facility failed to ensure the facility assessment was reviewed and updated as necessary, and at least annually for 1 of 1 facility. 1. The facility did not update the facility assessment to include Resident #15's gastrostomy (surgical procedure that creates an opening in the stomach, allowing for the insertion of a feeding tube (G-tube) for nutritional support). 2. The facility did not update the facility assessment to include Resident #36's oxygen and dialysis. These failures could affect residents by not having the necessary resources to ensure appropriate care is provided.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish policies in accordance with applicable Federal, State and local and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 2 of 4 residents (Resident #17 and Resident #36) reviewed for smoking. The facility failed to follow the policy on smoking by not completing a smoking screen assessment quarterly on Resident #17 and Resident #36. This failure could place residents at risk of unsafe smoking and injury.

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 in the facility's only kitchen reviewed for food and nutrition services. 1. The facility failed to ensure the can opener blade was free a black substance and a rusty-like material. 2. The facility failed to ensure 2 skillets, 5 large sheet pans, 3 small sheet pans, and 6 muffin pans were free from carbon build up on the cooking surface of the pan. 3. The facility failed to ensure the microwave was free from a thick, hard yellow substance, and a brownish substance resembling rust material on the inside top surface. These failures could place residents at risk of foodborne illness and food contamination.

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 diseases and infections for 2 of 14 residents (Resident #24 and Resident #36) and 1 laundry room reviewed for infection control practices and transmission-based precautions. 1) The facility failed to ensure LVN C provided proper hand hygiene during wound care to Resident #24's sacrum/coccyx area of the buttocks. 2) The facility failed to ensure the laundry staff were using a barrier when sorting contaminated linens. 3)The facility failed to ensure enhanced barrier precautions were initiated for Resident #36. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that the resident environment remained as free of accident hazards as was possible 1 of 14 resident (Resident #36) reviewed for quality of care. The facility failed to maintain resident use hot water at safe and comfortable temperature between 100 to 110 on Hall/Room where the hot water temperatures was 122 F on 10/09/2024. This failure could place residents at risk for sustaining scalding injuries when using resident accessible hot water.

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 of 14 residents (Resident #30) reviewed for pharmacy services. The facility failed to ensure MA A secured Resident #30's medications when she left Resident #30's medications on the top of the medication cart unattended. This failure could place residents at risk of not receiving drugs and biologicals as needed, medication errors, medication misuse, and drug diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide adequate supervision to prevent accidents for 1 (Resident #1) of 5 residents reviewed for elopement risk. The facility failed to ensure Resident #1did not elope from the facility and cross a four-lane highway 04/24/2024. The noncompliance was identified as PNC. The IJ began on 04/24/2024 and ended on 04/24/2024. The facility had corrected the noncompliance before the survey began. This failure could place all 5 residents who used a wander guard at risk for serious injuries.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure respiratory care was provided with professional standards of practice for 3 of 3 residents (Residents #7, #31, and #8) reviewed for respiratory care and services. 1. The facility failed to administer oxygen at 1L via nasal cannula as prescribed by the physician for Resident #7. 2. The facility failed to ensure Resident #31 and Resident #8's oxygen concentrator filters were cleaned. These failures could place residents who require respiratory care at risk for respiratory infections and exacerbation of respiratory distress.

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 RN coverage. The facility failed to provide RN coverage for 8 consecutive hours daily on 1/19/2023, 1/20/2023, 1/29/2023, 2/18/2023, 2/19/2023, 2/25/2023, 2/26/2023, 3/11/2023, 3/15/2023, 3/16/2023, 3/17/2023, 3/20/2023, 3/24/2023, 3/25/2023, 3/29/2023, 3/30/2023, and 3/31/2023. This failure had the potential to affect residents in the facility by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as an emergency care and disasters.

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 in the facilities only kitchen. The facility failed to ensure proper storage and labeling of food in airtight container after opening. The facility failed to ensure that trash was properly disposed of. The facility failed to ensure that kitchen staff appropriately restrained hair with the hairnet. The facility failed to ensure cans were free from damage. These failures could place residents at risk of cross contamination and foodborne illness.

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 1 resident (Resident #31) reviewed for hospice services. The facility did not ensure Resident #31's hospice records were a part of their records in the facility. This failure 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 treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 2 of 15 residents reviewed for resident rights. (Residents #18 and #7) 1. The facility failed to treat Resident #18 with respect and dignity when she received her lunch tray 25 minutes after the other resident at her table had already been served their meal and was eating in front of her. 2. The facility failed to ensure Resident #7's wanderguard was discontinued, after the elopement assessment indicated she was at no risk for elopement. These failures could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident was informed before, or at the time of admission, and periodically during the residents stay, of services available in the facility and of changes for those services, which included changes for services not covered under Medicare/Medicaid or by the facility's per diem rate for 2 of 3 residents (Residents #18 and #150) reviewed for Medicare/Medicaid coverage. The facility failed to ensure Resident #18 and #150 was given a SNF ABN when discharged from skilled services at the facility prior to covered days being exhausted. This failure could place residents at risk for not being aware of changes to provided services.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and comfortable homelike environment for 1 of 15 resident rooms (room [ROOM NUMBER]), 1 of 15 residents (Resident #46), 3 male shower rooms #1, #2 and #3 and 1 of 1 female bathrooms reviewed for physical environment. The facility failed to repair the trim in room [ROOM NUMBER]. The facility failed to replace the missing shower tile in male bathroom [ROOM NUMBER]. The facility failed to unclog the shower drain in the male bathroom [ROOM NUMBER]. The facility failed to ensure that the toothbrush in Resident #46 bathroom was labeled with Resident # 46 name and room number. The facility failed to ensure that the used single-use razors in the facility's male shower room [ROOM NUMBER] were discarded after use. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse for 2 of 15 residents (Resident #20 and Resident #14) reviewed for resident abuse. The facility did not ensure Resident #20 was free from abuse, as a result Resident #20 was physically assaulted by Resident #14 with no injuries. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents, for 2 of 15 residents (Resident's #44 and #33) reviewed for abuse. 1. The facility failed to implement the abuse and neglect policy and procedure regarding reporting fall incident. 2. The facility did not implement policy on reporting neglect for bruise of unknown origin for Resident #33 to the abuse coordinator (Administrator). These failures could place the residents at increased risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that all alleged violations involving abuse, neglect, exploitation, or mistreatment, including injuries of unknown source were reported immediately, but no later than 2 hours after the allegation was made, for 2 of 15 residents (Residents #44 and 33) reviewed for abuse and neglect. 1. The facility failed to report to the state agency within 2 hours of being notified of fall incident for Resident #44. 2. The facility failed to report Resident #33's bruised left arm, an injury of unknown origin, timely to HHS. These failures to report could place the residents at risk for abuse.

Inspectors wroteBased on interview, and record review the facility failed to ensure assessments accurately reflected the resident status for 1 of 5 residents (Resident #7) reviewed for MDS assessment accuracy. The facility did not ensure Resident #7's MDS assessment was accurately coded to reflect her level II PASRR status for mental illness. This failure could place residents at risk for not receiving care and services to meet their needs.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the pre-admission screening and resident review program (PASRR) to the maximum extent practicable to avoid duplicative testing and effort for 1 of 5 (Resident #15) residents reviewed for PASRR. The facility failed to refer Resident #15 for PASRR Level ll assessment when a diagnosis of Major Depressive Disorder was diagnosed after admission on [DATE]. This failure could affect residents with mental illnesses and place them at risk of not being assessed to receive needed services.

Inspectors wroteBased on interview and record review, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and timeframes to meet a resident's needs for 1 of 15 residents (Resident #7) reviewed for care plans. The facility failed to ensure Resident #7 care plan indicated she was PASRR positive. This failure could place residents at risk for unmet care needs and decreased quality of care.

Inspectors wroteBased on interviews and record review, the facility failed to implement a comprehensive person-centered care plan to meet resident's medical, nursing, mental and psychosocial needs identified in the comprehensive assessment for 1 of 15 residents (Resident #20) reviewed for care plans. The facility failed to ensure Resident #20's care plan was updated to not indicate a stage 3 pressure ulcer to his coccyx. This failure could place the resident at increased risk of not having their individual needs met and a decreased quality of life.

Inspectors wroteBased on interviews, and record review, the facility failed to ensure that residents who are trauma survivors receive culturally competent, trauma-informed care in accordance with professional standards of practice and accounting for residents' experiences and preferences in order to eliminate or mitigate triggers that may cause re-traumatization of the resident for 2 of 15 residents' (Resident #'s 7 and 31) reviewed for trauma-informed care. 1. The facility did not ensure Resident #7 had a trauma screening that identified possible triggers when Resident #7 had a history of trauma. 2. The facility did not ensure trauma screenings were completed upon admission to the facility. These failures could put residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure, in accordance with State and Federal laws, all drugs and biologicals were stored in locked compartments under proper temperature controls and permitted only authorized personnel to have access to the keys for 1 of 4 medication carts (Front Hall Cart) reviewed for storage of medications. The facility failed to ensure the Front Hall medication cart was locked when unattended. This deficient practice could place residents at risk of medication misuse and diversion.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide food that was palatable and served at an appetizing temperature for 4 of 19 residents (Resident's #28, Resident #5, Resident # 46, and Resident #22) reviewed for palatable food. The facility failed to provide palatable food served at an appetizing temperature or taste to Resident's #28, Resident #5, Resident # 46, and Resident #22 who complained the food was served cold and did not taste good. This failure could place residents who ate food from the kitchen at risk of weight loss, altered nutritional status, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the medical record was complete and accurately documented for 1 of 15 residents (Resident #35) reviewed for resident records. The facility failed to ensure LVN G accurately completed the elopement evaluation on Resident #35.

Inspectors wroteBased on observation, interview and record review, the facility failed to maintain an effective pest control program so the facility was free from pests and rodents for 1 of 1 kitchen reviewed for pest control. The facility failed to maintain an effective pest control program to ensure the facility kitchen was free from gnats. This failure could place residents at risk of unsanitary environment and decreased quality of life.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to follow their own established smoking policy for one visitor (Resident #31's family member) reviewed for smoking. The facility failed to ensure Resident #31's family member was smoking in the designated smoking area. The facility failed to ensure smoked cigarettes were extinguished in a fire-retardant receptacle.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS complete and accurate direct care staffing information, including information for agency and contract staff, based on payroll and other verifiable and auditable data in a uniform format according to specifications established by CMS fiscal year 2023 for the second quarter (January 1, 2023, to March 31, 2023) reviewed for administration. The facility failed to submit accurate RN hours for: 01/03 (TU); 01/04 (WE); 01/05 (TH); 01/09 (MO); 01/12 (TH); 01/13 (FR); 01/16 (MO); 01/23 (MO); 01/25 (WE); 01/27 (FR); 02/01 (WE); 02/03 (FR); 02/06 (MO); 02/07 (TU); 02/10 (FR); 02/15 (WE); 02/16 (TH); 02/20 (MO); 02/25 (SA); 02/26 (SU); 03/01 (WE); 03/02 (TH); 03/06 (MO); 03/10 (FR) This failure could place residents at risk for personal needs not being identified and met.