Avir at Luling

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 food and nutrition services. 1. The facility failed to ensure four packs of sliced bread and one pack of hotdog bread located on the bread rack in the facility kitchen was not past the best by dates. 2. The facility failed to ensure the handwashing sink was clean. 3. The facility failed to ensure there was a clean and functional step-on trash near the handwashing sink. 4. The facility failed to ensure the silver cart to distribute residents' food down the hall was clean. 4. The facility failed to ensure the blue crate to store dishes in the kitchen was clean. 5. The facility failed to ensure the AC in the unit in the kitchen was clean. [...]

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide a safe, clean, comfortable, and homelike environment and provide maintenances services to maintain sanitary, orderly and comfortable interior for 4 of 8 residents (Resident #1, Resident #2, Resident #3, and Resident #4) reviewed for homelike environment and resident rights. The facility failed to ensure Resident #1, Resident #2, Resident #3, and Resident #4 had functioning toilets and sinks in the bathrooms of their resident rooms. This failure could place residents at risk of living in an unclean or unsanitary environment, decreased quality of life, or shame.

Inspectors wroteBased on observation, interview, and record review the facility failed to maintain all mechanical, electrical, in safe operating condition for 1 of 1 kitchen reviewed for safe operating condition. 1. The facility failed to ensure refrigerator #2 maintained a safe storage temperature and not allow food items to be improperly stored.2. The facility failed to ensure the inside kitchen freezer maintained a safe storage temperature and did not allow food items to thaw. These failures pose a risk to all residents of the facility who eat food from the kitchen as they are at risk for food borne illnesses.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a safe, clean, comfortable, and homelike environment for four (Resident #6, Resident #14, Resident #31, and Resident #42) of eight residents reviewed for safe operating patient care equipment and for 1 of 1 kitchen reviewed for safe operating condition. A) The facility failed to ensure Resident #6, Resident #14, Resident #31, and Resident #42 had a functioning toilet in their rooms. This failure could place residents at risk of unsanitary conditions, and these failures pose a risk to all residents of the facility who eat food from the kitchen as they are at risk for food borne illnesses.

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 resident rights, that included measurable objectives and time frames to meet a resident's medical, nursing, mental, and psychosocial needs that were identified in the comprehensive assessment for 3 (Residents #51, Resident #38, and Resident #26 ) of 8 residents reviewed for care plans. 1. The facility failed to ensure that Resident #51's central venous catheter (a temporary access placed into a large vein in the neck or chest) for dialysis care was addressed in the comprehensive care plan. 2. The facility did not ensure Resident #38 had a care plan that identified possible triggers when Resident #38 had a history of trauma. 3. [...]

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 36 of 90 days (third quarter 2025) reviewed in that: The facility failed to ensure they had a RN on duty daily for 36 days of the 90 days in the third quarter from 04/2025 through 06/2025. This deficient practice placed residents at risk of missing nursing assessments, resident supervision and skilled nursing treatment.

Inspectors wroteBased on observations, record review and interviews, the facility failed to prepare food by methods that conserve nutritive value and flavor for 5 pureed diets of 1 of 1 kitchen reviewed for food and nutrition services. The facility failed to ensure [NAME] A and DM refrained from adding an unmeasured amount of liquid to spaghetti and meatballs, and green bean pureed meals during lunch service on 9/23/2025. This failure could place residents who received a pureed diet at risk for diminished or altered nutritional status and potential weight loss

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to properly store, prepare, distribute food in accordance with professional standards for food service safety for 1 of 1 kitchen. 1. The facility failed to label and date all food items located in refrigerators, freezers and in the dry food pantry area on 9/23/2025, 9/24/2025, and 9/25/2025. 2. The facility failed to discard expired food items located in the refrigerator and in the dry food pantry area. 3. The facility failed to ensure the trash containers were covered with lids on 9/23/2025, 9/24/2025, and 9/25/2025. 4. The facility failed to clean and sanitize its food storage areas, to include the freezers in the outside storage room on 9/23/2025, 9/24/2025, and 9/25/2025. These failures could place residents who received meals from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to ensure resident rights to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility for 1 of 8 residents (Resident #25) reviewed for resident rights. The facility failed to ensure Resident #25's door was closed when provided personal care to provide respect and dignity. This failure could place residents at risk of feeling uncomfortable, embarrassed and decreased privacy.

Inspectors wroteBased on interview and record review, the facility failed to coordinate assessments with the PASRR program for 1 of 5 residents (Resident #38) reviewed for PASRR assessments. The facility did not refer Resident #38 to the appropriate state-designated mental health authority for review when he received a new diagnosis of post-traumatic stress disorder (condition that develops following a traumatic event characterized by intrusive thoughts about the incident, recurrent distress/anxiety, flashback and avoidance of similar situations) or during readmission to the facility on [DATE]. This failure could place residents at risk of not being evaluated and receive needed PASRR services.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to review and revise the person-centered, comprehensive care plan for 1 (Resident #43) of 6 residents reviewed for comprehensive care plan revisions. The facility failed to update Resident #43's care plan to reflect his current need for assistance with his indwelling catheter bag placement after self-transfers. This failure could put residents at risk of not receiving the appropriate care, services, or treatments they need.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents who were incontinent of bladder received appropriate treatment and services to prevent urinary tract infections for one of two residents reviewed for catheters (Resident #43). The facility failed to ensure Resident #43's received care to prevent Urinary Tract Infections when they stored his catheter bag on the floor. These failures could place residents with foley catheters at risk for urinary tract infections and change of condition. Findings Included: Review of Resident #43's Face Sheet reflected he was admitted on [DATE] and readmitted on [DATE] with the following diagnoses cerebral infarction (the pathological process that results in an area of necrotic tissue in the brain.) encephalopathy (A medical term used to describe a disease that affects brain structure or function. [...]

Inspectors wroteBased on, interviews, and record review, the facility failed to ensure residents who were 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 1 of 4 residents (Resident # 38) reviewed for trauma-informed care. The facility did not ensure Resident #38 had a trauma screening that identified possible triggers when Resident #38 had a history of trauma. This failure could put residents at an increased risk for severe psychological distress due to re-traumatization.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 2 of 4 residents (Residents #13 and Resident #25) reviewed for infection control. The facility failed to ensure:1. TN used clean, sanitized scissors during wound care for Resident #25 on 09/24/2025.2. LVN D performed hand hygiene prior to preparing an injection for Resident #13 on 09/24/2025. 3. LVN D wore proper gloves (PPE) while administering an injection for Resident #13 on 09/24/2025. This failure could place residents at risk of exposure and/or possible transmission of communicable diseases and infections.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were free from physical abuse for one (Resident #1) of four resident reviewed for abuse. 1. 1. The facility failed to ensure Resident #1 was not physically abused by Resident #2 on 07/12/2025.2. 2. The facility failed to implement interventions to ensure Resident #1 was not physically abused by Resident #2 on 07/13/2025. This failure could place residents at risk of ongoing abuse, injury and psychosocial harmBased on interview and record review, the facility failed to ensure all residents were free from physical abuse for one (Resident #1) of four resident reviewed for abuse. 1. 1. The facility failed to ensure Resident #1 was not physically abused by Resident #2 on 07/12/2025. 2. 2. The facility failed to implement interventions to ensure Resident #1 was not physically abused by Resident #2 on 07/13/2025. [...]

Inspectors wroteBased on observation, interviews and record review, the facility failed to ensure each resident received adequate supervision and assistive devices to prevent accidents for 3 (Resident #1, Resident #2, and Resident #3) of 5 residents reviewed for accidents and hazards. A) The facility failed to ensure Resident #1 did not leave the facility without supervision and/or staff knowledge as Resident #1 was returned to the facility by a community member on 04/03/2025. B) The facility failed to ensure staff were educated that Resident #2 was a high elopement risk and implement interventions. C) The facility failed to ensure Resident #3's bed was in a low position with a fall mat in place when he fell on [DATE] and sustained a left hip fracture. A & B) These failures resulted in an Immediate Jeopardy (IJ) situation on 04/16/2025. The IJ template was provided on 04/16/2025 at 4:43 PM. [...]

Inspectors wroteBased on interviews and record review, the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, that included measurable objectives and timeframes to meet a resident's medical, nursing, mental, and psychosocial needs that were identified for two (Resident #2 and Resident #3) of five residents reviewed for care plans. 1. The facility failed to ensure Resident #2's elopement risk and interventions were included on his care plan. 2. The facility failed to ensure Resident #3's fall interventions were included on his care plan. These failures could place residents at risk of not receiving appropriate interventions to meet their needs.

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 8 of (03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025 ) 33 days reviewed for RN coverage. The facility failed to ensure they had an RN charge nurse on 03/15/2025, 03/16/2025, 03/22/2025, 03/23/2025, 03/29/2025, 03/30/2025, 04/11/2025, and 04/12/2025. This failure could place residents a risk of missed nursing assessments, interventions, care and treatment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to develop a baseline care plan that included instructions needed to provide effective and person-centered care of the resident for one (Resident #1) of three residents reviewed for baseline care plans. 1. The facility failed to ensure Resident #1's elopement risk and interventions were included on his baseline care plan. This failures could place residents at risk of not receiving appropriate interventions to meet their needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all alleged violations involving exploitation or mistreatment were reported immediately, but not later than 24 hours after the allegation was made, if the events that caused the allegation did not involve abuse or result in serious bodily injury, to the State Survey Agency in accordance with state law through established procedures for 1 (Resident #1) of 3 residents reviewed for misappropriation of property. The facility failed to report to the state agency when the facility was notified that CNA A requested and accepted money from Resident #1 on the weekend of 11/09/24 and 11/10/24. This failure could place residents at risk for further misappropriation.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents environment remained as free of accident hazards possible and ensure each resident received adequate supervision for one (Resident #1) of three residents reviewed for accidents and hazards. The facility failed to ensure Resident #1 was not missing from the facility on 10/07/24 for an unknown amount of time until EMS contacted and notified them that he was approximately .9 miles away and had fallen and found on the railroad tracks. Approximately 500 feet from the facility was a busy highway with through traffic of commercial vehicles to include semi-trucks. This failure resulted in an identification of an Immediate Jeopardy (IJ) on 10/10/24 at 2:47 PM and an IJ template was given. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure all alleged violations involving abuse or neglect were reported immediately or no later than 24 hours for one (Resident #1) of three residents reviewed for abuse and neglect. The facility failed to report to the State Agency an incident where Resident #1 eloped from the facility without staff knowledge and was found approximately an hour later after he had fallen on railroad tracks approximately one mile from the facility on 10/07/24. This failure could place residents at risk of abuse or and neglect.

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 kitchen sanitation, in that: 1. The facility failed to store clean plastic cups in a manner that allowed for air circulation. 2. The facility failed to ensure the tabletop can opener blade and base were free of buildup of grime and debris. 3. The facility failed to ensure an opened 5-lb. bag of pancake mix was stored in a sealed bag or container in the dry storage room. 4. The facility failed to ensure the interior racks, walls and floor of the reach-in refrigerator were free of dirt and debris. 5. The facility failed to ensure the low-temperature dishwasher reached 120 degrees Fahrenheit during the wash cycle. [...]

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 and employ a full time DON for 74 of 184 days reviewed in that: The facility failed to have an RN scheduled on 74 dates that were reviewed and has not had a fulltime DON since 7/31/24. This deficient practice could place residents at risk of not the nursing services received by the residents properly supervised. Record review of the facility's RN staffing hours from the time period of 3/1/24 through 8/31/24 revealed that an RN was not working in the building for an 8 hour shift on the following dates: [...]

Inspectors wroteBased on observation, record review, and interview, the facility failed to assist residents in obtaining routine dental care for 1 of 8 residents (Residents #33) reviewed for dental services in that: The facility failed to assist Resident #33 in obtaining needed dental services following referral to an oral surgeon for tooth extraction after being diagnosed with abscessed tooth. These failures could lead to pain and infection of teeth and gums.

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to ensure food was prepared in a form designed to meet individual needs for four of four residents (Residents #17, #20, #32 and #37) reviewed for food meeting residents' needs, in that: The DM did not puree the peach cobbler to a pudding or mashed potato consistency as required for Residents #17, #20, #32 and #37 who were ordered a pureed diet. This deficient practice could affect residents who received pureed meals from the kitchen by contributing to choking, poor intake, and/or 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 infection for 2 of 8 residents (Residents #39 and #47) and 1 of 2 halls (South Hall) reviewed for infection control, in that: 1. During a wound dressing change for Resident #39, LVN-F did not sanitize hands or change gloves in between removal of old dressing and cleansing and application of new dressing. 2. While providing incontinent care for Resident #47, CNA-E did not sanitize her hands in between glove changes when moving between soiled and clean incontinent pads, touched wipes dispenser with dirty gloves, and stored clean gloves in the front pocket of her scrubs where her cell phone was also stored. 3. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary, and comfortable environment for residents, staff, and the public for 1 of 1 facility reviewed for environmental concerns. 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a resident environment that was free of pests and rodents for 1 of 1 facility reviewed for effective pest control in that: The facility failed to provide a resident environment that was free of pests and rodents as live roaches were observed in resident rooms and in the kitchen. This deficient practice could place residents at risk of remaining in an environment that was not free of pests and rodents.

Inspectors wroteBased on interviews and record review, the facility failed to ensure the resident had the right to be informed of the risks, and participate in, his or her treatment which included the right to be informed in advance, by the physician or other practitioner or professional, of the risks and benefits of proposed care, of treatment and treatment alternatives, or treatment options and to choose the alternative or options he or she preferred, for 1 (Resident #6) of 6 residents reviewed for resident rights. The facility failed to obtain a signed consent for antipsychotic medication Ziprasidone and antidepressant medications Zoloft and Trazodone prior to their administration to Resident #6. [...]

Inspectors wroteBased on interview and record review the facility failed to develop and implement a comprehensive person-centered care plan that describes the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 of 8 residents (Residents #3 and #33) reviewed for care plans. The facility failed to ensure that: 1. Resident #3's order for Xarelto (a medication used to treat/prevent blood clots) was reflected in the resident's current comprehensive care plan. 2. Resident #33's use of Sertraline (a medication used to treat depression, also known as Zoloft) was reflected in the resident's current comprehensive care plan. This deficient practice could affect residents by contributing to missed or inaccurate care.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who was unable to carry out activities of daily living received the necessary services to maintain good personal hygiene for 1 of 8 residents (Resident #34) reviewed for hygiene, in that. Nursing staff failed to ensure Resident #34 received a shower and changed his stained shirt when his shower was scheduled on 09/04/2024. This deficient practice could place residents who were dependent on staff for ADL care at risk for loss of dignity, and/or a diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the environment remained as free of accident hazards as is possible for 1 of 23 Residents (Resident #22) reviewed for accident hazards in that: The facility failed to ensure Resident #22 was safe from hazards when there a small refrigerator (19x32 inches) placed on top of clothes drawer that was positioned near the head of the resident's bed. This deficient practice could place residents at risk of remaining in an environment that was not free of accident hazards and being injured as a result of the hazard.

Inspectors wroteBased on interview and record review, the facility failed to ensure residents' pharmacist medication regimen review recommendations were reviewed by the resident's attending physician and documentation of what, if any, action has been taken to address them, for 2 of 8 residents (Residents #3 and #33) whose records were reviewed for pharmacy services. The facility failed to ensure the Physician provided a clinical response to the consulting pharmacist's recommended changes which consisted of: 1. To ensure monitoring for side effects for Resident #3's Xarelto (a medication used to treat and prevent blood clots, commonly referred to as an anti-coagulant.); and 2. To clarify diagnosis for use of an anti-depressant, and for dose reduction consideration for that anti-depressant for Resident #33. This failure could place residents at risk for significant health status declines.

Inspectors wroteBased on interview and record review, the facility failed to ensure the resident was not given a psychotropic drug unless the medication was necessary to treat a specific condition as diagnosed and documented in the clinical record for 1 (Resident #33) of 8 residents reviewed for unnecessary medications, in that: Resident #33 was prescribed a psychotropic drug for depression without a documented diagnosis of depression in the clinical record. This deficient practice could place residents at risk of receiving unnecessary psychotropic medications.

Inspectors wroteBased on interview and record review, the facility failed to ensure a registered nurse was present in the facility for at least eight consecutive hours per day and seven days per week, for 22 of 93 day reviewed for registered nursing coverage, in that: The facility failed to ensure a registered nurse [RN] was present in the facility for at least eight consecutive hours per day and seven days per week on 22 separate occasions in the months of May 2023 - July 2023. This failure could place residents at risk of assessments, interventions, care and treatment requiring the advanced education, skills and judgement of an RN and leaving staff without supervisory coverage for coordination of events.

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure that all alleged violations involving abuse, neglect, including injuries of unknown source were reported immediately, 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, or not later than 24 hours if the events that cause the allegation do not involve abuse and do not result in serious bodily injury, to the administrator of the facility and to other officials (including to the State Survey Agency and adult protective services where state law provides for jurisdiction in long-term care facilities) in accordance with State law through established procedures for 1 of 18 residents (Resident #2) reviewed for abuse, neglect, and misappropriation of property, in that: [...]

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, in that: 1. The facility failed to ensure there was a foot operated, covered trash receptacle at the hand washing sink. 2. The facility failed to prevent an opened box of bacon in the main refrigerator past the use by date. These failures could place residents who received meals and/or snacks from the kitchen at risk for food borne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide reasonable accommodation of resident needs for 2 of 15 residents (Residents #6 and #9) reviewed for preferences, in that: 1. Resident #9's call light was unplugged. 2. Resident #6's call light was not within reach This failure could place residents who used call lights for assistance at risk in maintaining and/or achieving independent functioning, dignity, and well-being.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that the menus were followed for 2 of 2 meals observed in that: 1. mashed potatoes were served instead of scalloped potatoes for the lunch meal on 08/09/2023 2. green beans were served instead of breaded okra for the dinner meal on 08/10/2023 This failure could place residents at risk for dissatisfaction, poor intake, and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to establish policies, in accordance with applicable Federal, State, and local laws and regulations, regarding smoking, smoking areas, and smoking safety that also take into account nonsmoking residents for 2 of 2 residents (Residents #16 and #27) reviewed for smoking, in that: The facility failed to ensure Residents #16 and #27 did not have lighters in their possession. This failure could place residents at risk for smoking-related injuries and fires in the facility.