Avir at Lindale

Inspectors wroteBased on observation, interview, and record review the facility failed to have food available to meet the nutritional needs in accordance with established guidelines for 1 of 1 lunch meals reviewed. The facility failed to follow the posted menu on 6/10/26. The facility failed to ensure the kitchen staff properly portioned the spaghetti served during lunch on 6/10/26. The facility failed to ensure kitchen staff provided all residents with the same portion of mixed vegetables on 6/10/26. The facility failed to ensure the facility did not run out of garlic bread during lunch on 6/10/26. These failures could place residents at risk of decreased quality of life, poor intake, and/or weight loss.

Inspectors wroteBased on interview and record review, the facility failed to provide personal privacy when providing care for 1 of 9 (Resident #3) residents reviewed for privacy. The facility did not ensure CNA D and CNA E pulled the privacy curtain while providing incontinent care for Resident #3 on [DATE]. This failure could place residents at risk for diminished quality of life, loss of dignity and self-worth.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a resident who was unable to carry out activities of daily living received the necessary services to maintain grooming and personal hygiene were provided for 1 of 4 (Resident #1) residents reviewed for ADLs. The facility failed to ensure Resident #1's mouth, chin, and neck were cleaned on 6/9/26. The failure could place residents at risk of not receiving services/care and decreased quality of life. Findings Include: Record review of the face sheet dated 6/9/26 indicated Resident #1 was an [AGE] year-old female that was re-admitted to the facility on [DATE] with diagnoses including encephalopathy (any disease damage, or malfunction of the brain that alters its structure or function), cognitive communication deficit (an impairment in communication), dementia, intellectual disabilities, and anxiety. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure each resident received adequate supervision and assistance devices to prevent accidents for 1 of 9 (Resident #3) residents reviewed for accident hazards. The facility failed to ensure CNA D and CNA E used a gait belt (an assistive device used by caregivers and physical therapists to help patients safely stand, walk, or transfer between chairs and beds) when transferring Resident #3 from the wheelchair to the bed on [DATE]. The failure could place dependent residents at risk for falls, significant injuries and decreased quality of life. Findings Include: [...]

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 4 staff (ADON) and 1 of 5 (Resident #2) residents viewed for infection control. The facility failed to ensure the ADON performed hand hygiene between glove changes while providing wound care to Resident #2 on 6/9/26. This failure could place residents and staff at risk for cross-contamination, spread of infection and could potentially affect all others in the building. Findings Include: During an observation and interview on 6/9/26 at 10:18 a.m. revealed the ADON performed wound care on Resident #2 with assistance from CNA C. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food items were properly stored, prepared, distributed, and dated under sanitary conditions for 1 of 1 facility kitchens. The facility failed to ensure: *Eight cups containing a pudding-like substance were labeled or dated.*One container for pureed liquids was covered, dated, and labeled.*Four bowls of salads were labeled or dated.*Six cups of orange liquid were dated or labeled.*Three milk-like substances containers were dated or labeled.*Four cups of red liquid were dated or labeled.*One two-gallon pitchers, one with brown tea like liquid, and one with red liquid were dated or labeled.*The flour bin and cornmeal bulk bin did not have food storage bowl inside of the product bins.*An opened box of pinto beans was reclosed and sealed. 2. [...]

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: - there was soap in the dispenser at the handwash sink by the pantry door and in the dispenser in the bathroom.- a foot operated pedal trash can for each of the handwash sinks.- the sugar bulk bin did not have a scoop inside of product. - the microwave was kept clean.- the reach-in stainless steel freezers and coolers were free from food debris, dried liquid splatters and fingerprints.- thickened liquid products were dated when opened.- an opened box of a frozen food product was reclosed and sealed.- thawing hamburger meat was placed in a container or on a tray to catch meat juices.-a prepared pan of fruit gelatin was labeled and dated. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the menu was followed for 1 of 1 meals (lunch meal) reviewed for menus and nutritional adequacy. Dietary staff did not serve pureed bread during the noon meal on 02/09/26 to any residents eating pureed food provided by the dietary department. This failure could place residents who eat food from the kitchen at risk of not having their nutritional needs met.

Inspectors wroteBased on interview and record review, the facility failed to ensure MDS data was electronically transmitted to the CMS System within 14 days after completion of the assessment for 1 of 1 resident reviewed for assessments. (Resident #77) The facility did not transmit an admission MDS assessment within 14 days into the CMS system as required after Resident #77 was admitted . This failure could place residents at risk of having an incomplete record.

Inspectors wroteBased on observation and interview, the facility failed to post a list of names, addresses (mailing and email), and telephone numbers of all pertinent state agencies and advocacy groups in a form and manner accessible and understandable to residents and resident representatives for 1 of 1 facility bulletin. The facility failed to post the contact information for the Medicaid Fraud Control Unit in an accessible location. This failure could place residents at risk of not having access to the appropriate agency to report instances of fraud by a Medicaid provider.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents were provided reasonable access to receive their mail in a timely manner for 1 of 9 confidential residents (Confidential Resident #1) reviewed. The facility failed to implement a system to distribute incoming mail daily. This failure could place residents at risk of a delay in residents' personal correspondence, financial information, or other time-sensitive materials.

Inspectors wroteBased on observation and interview, the facility failed to display information on how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by such benefits for 1 of 1 facility bulletin. The facility failed to post the appropriate information in a location accessible to residents and their representatives. This failure could place residents at risk of delayed access to entitled benefits, interruption of services, and impaired ability to exercise informed decision-making regarding payment and coverage for their care.

Inspectors wroteBased on interview and record review, the facility failed to report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken for 1 of 6 residents (Resident #1) reviewed for abuse and neglect. The facility failed to ensure the provider investigation report was turned into the state survey agency (HHSC) within 5 working days of the reported incident for Resident #1. This failure could place residents at risk for abuse and neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to protect the residents' right to be free from physical abuse and neglect for 2 of 11 residents (Resident #4 and #5) reviewed for abuse, neglect, and exploitation in that: The facility failed to ensure Resident #4 was free from physical abuse on 10/6/25 at approximately 6:00 a.m. when CNA F grabbed her by the arm causing a skin tear. The facility failed to ensure Resident #5 was free from neglect on 5/14/25 when CNA G left her unattended in the shower. Resident #5 did not suffer an injury. These failures could place all residents at risk of loss of dignity, injury, and hospitalization.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents who are unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 3 of 11 residents (Resident #1, #2 and #3) reviewed for ADL care in that: The facility failed to ensure Resident #1 was provided appropriate incontinent care on 12/9/25 at 2:00 p.m. when she was observed wearing two briefs (double briefed) at the same time. The facility failed to ensure Resident #2 and Resident #3 was provided appropriate incontinent care at an unknown date and time when they said they had been double briefed in the facility. This failure could place all residents at risk of loss of dignity, skin breakdown, infection, and hospitalization.

Inspectors wroteBased on interviews and records review, the facility failed to provide adequate supervision for 1 of 3 residents (Resident #17) to prevent an avoidable accident. The facility failed to provide a timely response to the call light during change of shift for Resident #17 to prevent an avoidable accident. This resulted in Resident #17 having an actual fall on 08/09/2025, suffering a sprained left ankle injury. The failure could place residents at risk for accidents/ injury over which the facility had control, provided supervision, and assistive devices to each resident to prevent avoidable fall accidents.

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 1 of 1 kitchen. Staff were not wearing bearded hair nets 3 large baking sheets containing carbon build-up were stacked against each other Large and medium steam table pans stacked on rack contained moisture and water on the inside and food particles on the inside The three compartment Sink was stacked and dirty with dirty pots and pans in all three compartments Steam Table dirty with food splatter on glass Dried blood on floor by handwashing sink with no soap and paper towels to wash hands Trash in multiple areas of kitchen debris Open packaged meat, in a 2-door refrigerator, was not labeled, was not in a sealed container. [...]

Inspectors wroteBased on interview and record review, the facility failed to provide information to residents and their representatives on their rights related to filing grievances or concerns for 9 of 13 confidential residents. The facility failed to ensure 9 of 13 confidential residents were provided through postings in prominent locations; the Grievance Procedure, were provided access to the Grievance form, were provided information regarding who the facility grievance officer was, their contact information, and how to file an anonymous grievance. This failure could place the residents at risk of unresolved grievances and decreased quality of life.

Inspectors wroteBased on observations, and interviews, and record review the facility failed to serve food that was palatable for 1 of 1 meal reviewed for food palatability. (noon meal 10/28/2025). The facility did not provide palatable and appetizing food for the residents for the 10/28/2025 noon meal. Residents #1, 3, 4, 6, 11, 14, 15 and 19 complained of cold food and food that was not flavorful. These failures could place residents who received food from the kitchen at risk for diminished meal satisfaction and potential weight loss due to poor meal intake.

Inspectors wroteBased on observations, interview and record review the facility failed to ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice for 2 of 3 residents (Resident #1 and Resident #2) reviewed for tracheostomy care. The facility failed to ensure proper care was provide to Resident #1 on 12/7/24 when she was in respiratory distress due to her tracheostomy's inner cannula (a removable, cylindrical tube that fits inside the outer cannula of a tracheostomy tube) being obstructed resulting in Resident #1 being hospitalized . The facility failed to ensure they had full-time qualified staff to perform proper tracheostomy care on Resident #2's tracheostomy in accordance with professional standards. [...]

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 6 of 7 residents (Resident #3, Resident #4, Resident #5, Resident #6, Resident #7, and Resident #8) and 6 of 7 staff (CNA M, CNA N, the Treatment Nurse, CNA P, CNA L and CNA R) observed for infection control. The facility failed to ensure CNA M and CNA N changed gloves and performed hand hygiene while performing incontinent care on Resident #4. The facility failed to ensure CNA N did not use a disposable wipe more than once when performing incontinent care on Resident #4. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to treat each resident with respect and 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 1 of 7 residents (Resident #3) reviewed for dignity. The facility did not ensure Resident #3's urinary catheter drainage bag was covered on 2/6/25, 2/7/25, and 2/11/25. These failures could place residents at risk of a diminished quality of life, loss of dignity and self-worth.

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 dry pantry was clean and food containers were kept clean. The facility failed to ensure food items were labeled or dated. The facility failed to ensure the freezers and coolers were clean inside and outside. The facility failed to ensure potentially hazardous food items were thawed in a way to contain liquid seepage. The facility failed to ensure the deep fryer was clean and contained fresh grease. The facility failed to ensure stainless steel serving pans were air dried before stacking and storing. These failures could place residents who ate food from the kitchen at risk of foodborne illness.

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 1 of 4 residents (Resident #286) reviewed for baseline care plans. The facility failed to ensure Resident #286's baseline care plan included instructions to address his admission physician orders for fluid restrictions within 48 hours of admission. This failure could place newly admitted residents at risk for not receiving the appropriate care and services to maintain the highest level of well-being.

Inspectors wroteBased on interview, and record review, the facility failed to maintain grooming and personal hygiene for 1 (Resident #336) of 1 resident reviewed for activities of daily living care. The facility failed to ensure showers were provided to Resident #336, on her scheduled shower days. This failure could place residents at risk for social isolation and a loss of dignity and self-worth.

Inspectors wroteBased on interview and record review, the facility failed to maintain acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise for 1 of 4 residents reviewed for hydration status (Resident #286). The facility failed to ensure Resident #286's physician's order for fluid restrictions was initiated and was communicated to the nursing and dietary departments for 8 (eight) days. The facility failed to clarify the physician's order for fluid restrictions to include the breakdown of the amount of fluid per 24 hours to be distributed between the dietary and nursing departments. [...]

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure pharmaceutical services were provided to meet the needs of 1 of 4 residents reviewed for pharmacy services (Residents #286). The facility failed to ensure MA C did not leave Resident #286's medications at bedside unattended. This failure could place residents at risk of not receiving medications as ordered by the physician.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents had the right to be fee from abuse, neglect, misappropriation of resident property, and exploitation for 2 of 4 residents (Resident #1 and Resident #2) reviewed for neglect. 1. The facility failed to ensure the former DON was aware AED pads (AED pad are a vital part of the AED machine that are used to help people experiencing sudden cardiac arrest. The AED pads are place on the person's bare chest and are attached to a cable that connects to the AED to the patient body. [...]

Inspectors wroteBased on interview and record review the facility failed to provide basic life support, including CPR, to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the residents advanced directives for 1 of 4 residents reviewed for emergency care. (Resident #1) 1. Resident #1 a full code status ( a medical code status that indicated to take all steps to save the residents life in the event of cardiac or respiratory arrest, including CPR) turned blue and had no pulse or heart rate, the facility staff requested the crash cart (a cart with emergency medical supplies) when the cart arrived the emergency supplies were missing. 2. The crash cart did not have AED pads for the AED- defibrillator (AED pad are a vital part of the AED machine that are used to help people experiencing sudden cardiac arrest. [...]

Inspectors wroteBased on interviews 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 Residents (Resident #1) reviewed for pressure injuries. The facility failed to prevent deterioration for Resident #1 of MASD of bilateral buttock to a necrotic unstageable pressure ulcer. The facility failed to ensure wound care was provided twice a day as ordered to Resident #1's MASD of the bilateral buttocks to prevent deterioration. Resident #1 did not receive 6 of 10 wound care treatments to his bilateral buttocks. The facility failed to follow their policy by not assessing Resident #1's deteriorating wound. [...]

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 2 of 6 residents (Resident #1 and Resident #2) reviewed for baseline care plans. The facility failed to ensure Resident #1 and Resident #2 had baseline care plans completed within 48 hours of admission. This failure could place newly admitted residents at risk of receiving inadequate care and services.

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 resident rights for 2 of 6 (Resident #1 and Resident #2) residents reviewed for care plans, The facility failed to ensure Resident #1's code status was properly care planned. The facility failed to ensure Resident #2 had a care plan completed. This failure could place the residents at increased risk of not having their individual needs met and a decreased quality of life. Findings Included: 1. Record review of the face sheet dated 5/7/24 indicated Resident #1 was a [AGE] year-old male admitted to the facility on [DATE] with diagnoses including heart failure, muscle weakness, diabetes, hypertension (elevated blood pressure), and difficult walking. [...]

Inspectors wroteBased on interview and record review, the facility failed to consult with the physician when the resident experienced a change in condition / a need to alter treatment significantly for 1 (Resident #1) of 6 residents reviewed for a change of condition. The facility failed to notify the physician when Resident #1 refused all oral medications for 4 days ([1/18/24 to 1/21/24], which included Furosemide, Isosorbide Mononitrate ER, Carvedilol, Sacubitril-Valsartan [medications used in the treatment of heart failure] and Metformin HCl [ used to treat diabetes]) leading up to his hospitalization on 1/22/24 during which he was diagnosed with urosepsis. The facility failed to notify the physician when Resident #1 refused to have ordered labs (CBC, CMP and UA) obtained on 1/17/24, which would have identified an urinary tract infection. [...]

Inspectors wroteBased on observations, interviews, and record review the facility failed to ensure a resident who had a urinary catheter received appropriate treatment and services to prevent urinary tract infections and pain for 1 of 6 (Resident #1) residents reviewed for urinary catheters. The facility did not ensure the needed an order for catheter care was entered when Resident #1 returned from the hospital with a Foley catheter in place on 1/1/24. The facility did not ensure catheter care was documented for Resident #1 from 1/1/24 to 1/17/24. The facility did not ensure Resident #1 was provided catheter care from 1/1/24 to 1/17/24. The facility did not clearly document the discontinuation of Resident #1's foley catheter or circumstances for it's discontinuation. Resident #1 was admitted to the hospital on [DATE] and was found to have Urosepsis (sepsis caused by infections of the urinary tract). [...]

Inspectors wroteBased on interviews, and record review, the facility failed to provide care that would ensure acceptable parameters of nutritional status for 1 of 6 residents reviewed for nutritional status. (Resident #1). The facility did not appropriately monitor Resident #1's weights during his stay at the facility from 12/21/23 to 1/22/24 and it resulted in Resident #1 had a 15 % weight loss in 26 days. This noncompliance was identified as PNC. The non-compliance began on 12/21/23 and ended 2/29/24. The facility had corrected the non-compliance before the survey began. This failure could place residents at risk for altered nutritional status, and complications of chronic conditions, and decline in health status.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to prevent development of pressure ulcers and promote healing of existing pressure ulcers for 2 of 8 residents (Residents #331 and #15) reviewed for pressure ulcers. The facility failed to provide low air loss mattresses to reduce/redistribute pressure to the affected areas and promote healing (Residents #331 and #15) The facility failed to reduce direct pressure to Resident # 331's bilateral heels and resident #15's left heel by off-loading the heels with use of pillows or other pressure relieving devise. The facility failed to provide dietary interventions timely to Resident #331. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a centralized staff work area, for 1 of 11 residents reviewed for call lights. (Resident #44). The facility did not adequately equip Resident #44 with a call light to allow residents to call for assistance. This failure could place residents who rely on the call light system to have delayed response to meet their needs.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents fed by enteral means received the appropriate treatment and services to prevent complications of enteral feedings for 1 of 3 residents (Residents #69) reviewed for tube feeding. The facility failed to apply a gauze dressing to Resident #69's enteral stoma site per physician order. This failure could place residents who require enteral feedings at risk for infections and hospitalizations.

Inspectors wroteBased on observation, interview and record review, the facility failed to ensure that respiratory care was provided consistent with professional standards of practice for 1 of 7 residents (Residents #69) reviewed for respiratory care. The facility failed to place Resident #69's nebulizer tubing in a bag when not in use. This failure could place residents who require respiratory care at risk for respiratory infections.