Avir at Overton

Inspectors wroteBased on observation, interview and record review, the facility failed to implement written policies and procedures that prohibit and prevent abuse 1 of 4 residents (Resident #1) reviewed for developing and implementing abuse and neglect policies. 1. The facility failed to report to the state and thoroughly investigate an allegation of abuse reported on 5/3/26 after the hospitality aide reported to the ADM, DON, and ADON that CNA B was being rough with Resident #1 in the shower. 2. The facility failed to report to the state and thoroughly investigate an allegation of abuse on 5/3/26 after a housekeeper observed CNA B forcefully push Resident #1 down into a dining room chair while Resident #1 stated no, no, no. These failures resulted in an identification of an Immediate Jeopardy (IJ) on 5/19/26 at 2:41 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 3 of 3 months (October, November, and December 2025) reviewed for Quarter 1 of the fiscal year 2026. The facility did not have RN coverage for 3 days in October 2025. The facility did not have RN coverage for 4 days in November 2025. The facility did not have RN coverage for 5 days in December 2025. This failure could place residents at risk by leaving staff without supervisory coverage for RN specific nursing activities and for coordination of events such as emergency care and disasters.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to provide a safe, clean, comfortable, environment with 2 of 6 halls (Hall A and Hall F) reviewed for environment. The facility failed to ensure ceiling tiles were secure on Halls A and F on 4/27/2026. This failure could place the residents at risk of living in an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, clean, and comfortable environment for residents for 3 of 15 residents (Resident #9, Resident #13, and Resident #43) observed for resident environment. The facility failed to ensure the floor in Resident #9 and Resident #13's room did not have damaged and missing bathroom flooring and base of toilet was free of a soiled appearance on 4/27/2026-4/29/2026. The facility failed to ensure the blinds in Resident #43's room were not broken and bent on 4/27/2026-4/29/2026. These failures could place residents at risk for an unsanitary and comfortable environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program so that the facility was free of pests and rodents for 1 of 1 kitchen reviewed for pest control. The facility failed to ensure the kitchen remained free from roaches on 04/28/2026, during the lunch meal, when a roach was observed crawling on the wall. This failure could place residents at risk for reduced quality of life and poor sanitary environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure it formulated, adopted, and enforced policies regarding smoking, smoking areas, and smoking safety that also consider non-smoking residents for 1 of 2 smoking areas (outside dining room) reviewed for smoking safety. The facility failed to ensure paper was not discarded into the ashtrays and cigarettes butts were not placed in the trash can on 4/27/2026. This failure could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on interview and record review the facility failed to immediately inform the resident, consult with the resident's physician; and notify, consistent with his or her authority, the resident representative where there was a significant change in the resident's physical, mental, or psychosocial status and when there was a need to alter treatment significantly for 1 of 2 residents (Resident #1) reviewed for falls. The facility failed to notify Resident #1's responsible party when he fell on 6/22/26 resulting in a laceration to the bridge of his nose. The facility failed to notify Resident #1's attending physician and responsible party when he fell on 6/27/26. These failures could place residents at risk for delayed treatment, not receiving necessary treatments and medications, and a decreased quality of life.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered careof the residents that meet professional standards of quality care for 1 of 6 residents (Resident #1) reviewed for baseline care plans. The facility failed to ensure Resident #1's baseline care plan was completed within 48 hours of admission on [DATE]. This failure could affect residents by not addressing their physical, mental, and psychosocial needs for each resident to attain or maintain their highest practicable physical, mental, and psychosocial outcome.

Inspectors wroteBased on interviews, and record reviews, the facility failed to ensure that residents received care and services in accordance with professional standards of practice for 2 of 5 residents (Resident #1 and Resident #2) reviewed for quality of care. The facility failed to ensure Resident #1 and Resident #2 were assessed for injury following a motor vehicle accident on 12/19/2025 in the facility transport van. This failure could place residents at risk for not receiving appropriate care and treatment and/or decline in their health.

Inspectors wroteBased on observations, interviews, and records review the facility failed to ensure residents were free from abuse for 1 of 6 residents (Resident #1) reviewed for abuse, neglect, and exploitation. The facility failed to ensure Resident #1 was free from physical abuse on 10/19/25 at approximately 5:46 p.m. when Resident #2 stomped on Resident #1's foot. This failure could place residents at risk of pain, injury, hospitalization, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and records review the facility failed to ensure that all alleged violations involving abuse were reported immediately, but not later than 2 hours, for 1 of 6 residents (Resident #1) reviewed for abuse. The facility failed to ensure RN A and CNA B reported an allegation of abuse to the ADM immediately when Resident #2 stomped Resident #1's foot on 12/19/25. This failure could place residents at risk of continued abuse which could lead to risk of pain, injury, hospitalization, and diminished quality of life.

Inspectors wroteBased on observations, interviews, and records review, the facility failed to ensure residents' right to a dignified existence for 1 of 5 residents (Resident #1) reviewed for Resident Rights. The facility failed to ensure CNA A provided privacy for Resident #1 on 11/12/25 at approximately 2:15 p.m. during incontinent care when she left the room without closing the privacy curtain or covering the resident for privacy. This failure could place residents who require incontinent care at risk of psychosocial harm and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents remained free from physical abuse for 1 of 8 residents (Resident #1) reviewed for physical abuse. The facility failed to protect Resident #1 from resident-to-resident physical abuse on 7/16/25 when Resident #2 hit Resident #1 with a television cord, a nightstand drawer, and a wheelchair footrest causing injuries including facial and scalp lacerations, a fractured globe of the left eye, and a nasal fracture. An Immediate Jeopardy (IJ) situation was determined to have begun on 7/16/2025 and ended on 7/18/25. It was determined to be past non-compliance due to the facility having implemented actions that corrected the non-compliance prior to the beginning of the survey. This failure could place all residents at risk for serious injury and hospitalization.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 8 residents (Resident #3) reviewed for accidents. The facility failed to keep Resident #3 in a safe environment to prevent an elopement on 7/27/2025 when he followed visitors out of the facility. An Immediate Jeopardy (IJ) situation was determined to have begun on 07/27/2025 and ended on 08/01/2025. It was determined to be past non-compliance due to the facility had corrected the noncompliance before the survey began. This failure could place residents at risk for serious injury and accidentsFindings included: [...]

Inspectors wroteBased on interview and record review, the facility failed to use the services of a registered nurse for at least eight consecutive hours a day, 7 days a week for 2 of 3 months (July 2024 and August 2024) reviewed for Quarter 4 of the fiscal year 2024. The facility did not have RN coverage for 4 days in July 2024. The facility did not have RN coverage for 1 day in August 2024. This failure could place residents at risk 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 ensure food was stored, prepared, and distributed under sanitary conditions in one of one kitchen reviewed for dietary services. The facility did not ensure the dish machine was working properly on 02/17/2025. The facility did not ensure that raw foods were thawed appropriately on 02/17/2025. These failures could place residents who eat from the kitchen at risk of foodborne illnesses.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and sanitary environment for residents on hallway B (Women's locked Unit, Resident #8) and C (men's locked unit), 1 of 3 dining rooms (main dining room) and main dining room patio reviewed for physical environment. The facility failed to provide Resident #8 a safe, clean and sanitary environment on 02/17/25 to 2/18/25 when the mattress on her bed was stained with a brown substance, the wall next to her bed was smeared with a dirty yellow, red and brown substance and had exposed sheetrock. The facility failed to maintain the wall in Resident #8's bathroom leaving the sheetrock exposed at the sink and non- working soap dispenser in the bathroom. The facility failed to maintain walls, doors, doorways, and floors to residents residing on Hallways A and B. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the residents' environment remained as free of accident hazards as possible for 1 of 8 residents (Resident #21) reviewed for accidents/hazards. The facility failed to remove a worn and damaged mechanical lift sling from service on 2/17/2025 and 2/18/2025. This deficient practice could place residents at risk of a loss of quality of life due to injuries.

Inspectors wroteBased on observation and interview, the facility failed to ensure nurse staffing data was posted daily and readily accessible to residents and visitors with all required information for 2 of 2 days reviewed (2/17/2025 and 2/18/2025) for nurse staffing posting. The facility failed to post the daily staffing information in a prominent place on 2/17/2025 and 2/18/2025. This failure could place residents, families, and visitors at risk of not being informed of the census and number of staff working each day to provide care on all shifts.

Inspectors wroteBased on interview and record review, the facility failed to ensure all residents were free from neglect for 1 of 5 residents (Resident #1) reviewed for neglect. RN A did not call 911 for emergency services for Resident #1 until approximately 29 minutes after discovering Resident #1 unresponsive on [DATE]. CPR was not initiated on Resident #1 on [DATE] until approximately 9:52 PM when Fire Department arrived and began resuscitation attempts. Resident #1 was pronounced deceased at approximately 10:27 PM after Justice of the Peace arrived. The facility staff failed to provide life saving measures to Resident #1 who was identified as being full code after he was found unresponsive in his room. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:50 p.m. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure basic life support, including cardiopulmonary resuscitation (CPR), was provided to a resident requiring such emergency care prior to the arrival of emergency medical personnel and subject to related physician orders and the resident's advance directives for 1 of 5 (Resident #1) residents reviewed for CPR. The facility failed to ensure staff performed CPR on [DATE] for Resident #1 who was identified as a full code . CPR was not initiated prior to emergency services arrival. The facility failed to ensure staff utilized the AED on [DATE] when Resident #1 was found unresponsive. The facility failed to follow their policy and procedure for Emergency Procedure - Cardiopulmonary Resuscitation. These failures resulted in an identification of an Immediate Jeopardy (IJ) on [DATE] at 5:50 p.m. [...]

Inspectors wroteBased on interviews and record reviews, the facility failed to ensure the residents had the right to be free from abuse for 3 of 11 residents (Residents #1, #2 and #3) reviewed for abuse. The facility failed to protect Resident #2 from Physical Abuse when Resident #1 slapped her in the face on 10/27/2024. The facility failed to protect Resident #1 from Physical Abuse when Resident #3 pulled Resident #1 by her shirt collar on 12/11/2024. This failure could place residents at risk for abuse, physical or psychological harm or injury.

Inspectors wroteBased on observation, interview, and record review the facility failed implement their written policies and procedures to report an allegation of abuse as required for 1 of 4 residents reviewed for abuse (Resident #1). The facility did not report to HHSC after Resident#1 alleged CNA A and LVN B called him a wet back (a racial slur). This negative finding could cause continued abuse.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure food was stored, prepared, and distributed under sanitary conditions in one of one kitchen reviewed for dietary services. The facility failed to ensure the floor in the pantry was clean and did not have roaches crawling on the floor. The facility failed to ensure the grease in the deep fryer was black and there was food debris in the fryer. The facility failed to remove two dirty five gallons buckets in the corner of the dining room beside the ice machines. The facility failed to ensure the floor behind and under the ice machines were clean. These failures could place residents at risk of illness and have a decrease mood related to the condtion of their home.

Inspectors wroteBased on interview and record review, the facility failed to electronically submit to CMS (Centers for Medicare & Medicaid Services) 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 reviewed for administration. (Fiscal year 2023 for the third quarter April 1, 2023, to June 30, 2023) The facility failed to submit accurate licensed nurse hours for the following dates: 4/30/2023, 5/6/2023, 5/14/2023, 5/20/2023, 5/28/2023, 6/3/2023, 6/4/2023, 6/10/2023, 6/11/2023, 6/17/2023, 6/18/2023, 6/24/2023, and 6/25/2023. This failure could place residents at risk for personal needs not being identified and met.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide pharmaceutical services, including procedures that assures the accurate acquiring, receiving, dispensing, and administering of medications in 1 of 1 medication storage rooms reviewed for pharmacy services. The facility did not dispose of expired medications from the medication storage room (PPD-Mantoux Testing). This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to store all drugs and biologicals in locked compartments/rooms for 1 of 1 medication room (the only medication room in the facility) reviewed for medication storage, in that: The facility failed to secure the medication storage room. This failure could place residents at risk for drug diversion and harm if the medication room was accessed by a resident and medications were consumed.

Inspectors wroteBased on observation, interview and record review, the facility failed to provide drinks, including, water and other liquids, consistent with resident needs and preferences for 1 of 1 Meals ( lunch) observed for hydration. The facility failed to provide drinks, including water, during lunch on 12/04/2023. The facility did not follow the resident's tray cards and serve 8 fluid ounces of water to the residents served lunch in the dining room and on Halls A, B, C, E, F. This failure could place residents at risk for thirst, dehydration, and decreased quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to maintain an effective pest control program to keep the facility free of pest. The facility did not have an effective pest control program in place to keep roaches out of 1 of 1 kitchen supply room. This failure could place residents at risk for the potential spread of infection, cross-contamination, and decreased quality of life.

Inspectors wroteBased on interview and record review, the facility failed to complete a significant change MDS assessment within 14 days after a significant change in the resident's mental and physical condition for 1 of 12 residents (Resident #4) reviewed for assessments in that: The facility failed to reassess Resident #4 for his hospice (specific care for the sick or terminally ill) status. This failure could place residents at risk for not having their individual needs met due to inaccurate assessments.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free from abuse for 5 of 6 residents (Resident #3, Resident #20, Resident #21, Resident #23, and Resident #24) reviewed for Resident Abuse. 1. The facility failed to protect Resident #3 from abuse by Resident #20. On [DATE] Resident #20 tried to choke Resident #3. 2. The facility failed to protect Resident #21 from abuse by Resident #20. On [DATE] Resident #20 attempted to strike Resident #21 and both fell to floor. 3. The facility failed to protect Resident #3 from abuse by Resident #20. On [DATE] Resident #20 bit Resident #3 on the thumb causing a skin tear, leading to an infection requiring treatment. 4. The facility failed to protect Resident #20 from abuse by Resident #23. [...]

Inspectors wroteBased on observation, interviews, and record reviews, the facility failed to implement written policies and procedures that prohibit abuse/neglect for 5 of 6 residents (Resident #3, Resident #20, Resident #21, Resident #23, and Resident #24) reviewed for incidents. The facility failed to implement their abuse policy and program to prevent abuse when: 1. On 6/5/23 Resident #20 tried to choke Resident #3. 2 On 6/14/23 Resident #20 attempted to strike Resident #21 and both fell to floor. 3. On 6/14/23 Resident #20 bit Resident #3 on the thumb causing a skin tear, leading to an infection requiring treatment. This incident was not investigated or reported. 4. On 6/20/23 Resident #20 was involved in an altercation with Resident #23 and Resident #23 hit Resident #20 causing him to fall. 5. On 8/21/23 Resident #20 wandered into Resident #25's room and Resident #25 hit Resident #20 on the head. [...]

Inspectors wroteBased on observation, interview and record review, the facility Quality Assurance and Performance Improvement committee (QAPI) failed to develop and implement appropriate plans of action to correct and identify quality deficiencies for 1 of 1 facility. The facility QAPI failed to identify and implement an action plan to address multiple, resident to resident altercations, that occurred on 6/5/23, 6/14/23, 6/20/23, 8/21/23 and 9/18/23. The facility QAPI failed to identify and implement an action plan to address an elopement that occurred on 6/6/23. These failures resulted in an Immediate Jeopardy (IJ) situation identified on 10/25/23 at 3:49 PM. [...]

Inspectors wroteBased on interview, and record review, the facility failed to consult with the physician when the resident experienced a change in condition for one (Resident #3) of nine residents reviewed for a change of condition. The facility failed to notify the physician of a change in condition for Resident #3 after he had thick hardened secretions that could not be removed from his tracheostomy on [DATE] at 10:51 PM. Resident #3 was transported to the hospital in cardiac arrest and later passed away. An Immediate Jeopardy was identified on [DATE] at 7:11 PM. While the Immediate Jeopardy was removed on [DATE] at 5:31 PM, the facility remained out of compliance at a scope of isolated and a severity level of actual harm that is not Immediate Jeopardy due to the facility's need to monitor and evaluate the effectiveness of the plan of removal and corrective actions. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide adequate supervision and assistance to prevent accidents for 3 of 3 residents reviewed for accidents/supervision (Resident #3, Resident #20, and Resident #26) in that: 1. The facility failed to provide adequate supervision to prevent resident #3's exit from the secured unit on 8/18/23 and 9/2/23. Resident #3 was able to get out of a side door when opened from other side by other staff/residents on 8/18/23 and 9/2/23. 2. The facility failed to provide adequate supervision to prevent resident #20's exit from the secured unit on 5/27/23, 6/1/23, and 6/6/23. Resident #20 was able to get out of side door to secured unit when opened from other side by staff or other residents on 5/27/23 and 6/1/23. [...]

Inspectors wroteBased on interview and record review, the facility failed to ensure each resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences for 1 (Resident #3) of 9 residents reviewed for assistive devices. The facility failed to promptly identify and intervene when Resident #3 had thick hardened secretions in his tracheostomy. Resident #3 was transported to the hospital in cardiac arrest and later died. An Immediate Jeopardy was identified on [DATE] at 7:11 p.m. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure residents received treatment and care in accordance with professional standards of practice and the comprehensive person-centered care plan for 1 of 4 residents (Resident #3) reviewed for quality of care in that: RN A failed to clean Resident #3's wounds after she removed the dressings. This deficient practice could affect residents who receive wound care from the facility staff and place them at risk for worsening skin conditions.

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 (RN A) staff reviewed for infection control in that: RN A did not wash or sanitize her hands in between glove changes while performing wound care to Resident #3. During wound care RN A failed to clean Resident #3's wounds after she removed the old dressings from wounds on both legs and her right foot. These failures could place residents at risk of exposure to communicable diseases and infections. Findings Included: [...]