Avir at Petal Hill

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure residents received adequate supervision to prevent accidents for 1 of 19 residents reviewed for accidents. (Resident #1). The facility failed to ensure adequate supervision and implementation of safety interventions for Resident #1 who resided on a secured unit and was assessed to be at risk for elopement. This resulted in Resident #1 exiting the building on 04/30/2026 without staff knowledge or supervision, placing the resident at risk for harm. The noncompliance was identified as PNC (past noncompliance). The IJ began on 04/30/2026 and ended on 05/06/2026. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of potential accidents, injuries, harm, or death.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, functional, sanitary and comfortable environment for one of one rooms (the primary therapy room) reviewed for environment. The facility failed to ensure residents were not exposed to mold growing in the air vents in the primary therapy room. This failure could place residents at risk for respiratory infections and allergic reactions.

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 and misappropriation of resident property, were reported immediately, but not later than two hours after the allegations were made, if the events that caused the allegation involved abuse or resulted in serious bodily injury for one of seven residents (Resident #1) reviewed for abuse. The facility failed to report an allegation of abuse to HHSC until approximately 5 hours after the incident occurred. This failure could place residents at risk of not receiving timely investigation into allegations of abuse.

Inspectors wroteBased on interviews and record review, the facility failed to provide a private space for resident group meetings for 6 of 6 confidential residents interviewed. The facility failed to ensure the resident group had a meeting space available that was private and uninvited staff were not present during the meetings. This failure could place residents at risk for reluctance to voice their concerns due to staff members being present.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the accurate acquiring, receiving, dispensing, and administering of all drugs and biologicals to meet the needs of each resident for two of two residents (Resident # 1 and Resident # 81), two of four medication carts ( LVN Cart #1 and RN Cart #2), and one of two mediation storage rooms reviewed for pharmacy services. LVN D failed to use the proper technique for administration of eye drops for Resident #1 on 3/4/2026. LVN B failed to use the proper technique for administration of eye drops for Resident #81 on 3/5/2026. RN A signed the controlled substance count sheets for the end of their shift at the beginning of their shift on RN Cart #2 on 3/5/2026. LVN B signed the controlled substance count sheets for the end of their shift at the beginning of their shift on LVN Cart #1 on 03/5/2026. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to coordinate the assessment of 1 of 6 residents (Resident #6) reviewed for the pre-admission screening and resident review (PASRR) program and PASRR assessments and evaluations. The facility failed to ensure Resident #6 had an accurate Level 1 PASRR screening that reflected an active mental illness diagnosis. This failure could place residents with mental illness diagnoses at risk of not being evaluated for and potentially not receiving PASRR services for care and treatment.

Inspectors wroteBased on interview and record review the facility failed to submit a complete and accurate request for NFSS in the LTC Online Portal for 1 of 3 residents reviewed for PASRR assessments (Resident #1). The facility did not ensure the required NFSS form for Resident #1 to receive an OT Assessment and OT Services was submitted within 20 business days (6/21/2024) of the IDT meeting held for Resident #1 on 5/22/24 to the PASRR department via the LTC Online Portal. This failure could place residents who are PASRR positive at risk of not receiving the necessary services that would enhance their quality of life.

Inspectors wroteBased on interview, observation, and record review the facility failed to ensure residents were free from physical abuse for 2 of 8 residents reviewed for abuse. (Resident #s 1 and 2) The facility failed to ensure Resident #2 was free from physical abuse when Resident #1 threw Resident #2 against the wall in the hallway of the secured unit causing Resident #2 to hit her head on the corner of the wall and fall onto the floor resulting in a closed head injury and a fractured lumbar vertebra on 5/13/25. The noncompliance was identified as past noncompliance (PNC). The IJ began on 5/13/25 and ended on 5/14/25. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for physical abuse, mental abuse, emotional abuse, and harm.

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 17 or 25 rooms (Room #'s A1, A2, A3, A4, A5, A6, A7, A8, A9, A10, B10, B11, C12, C14, C15, C16, C17, C18, C19, C19, C20, C21, and C22) reviewed for environmental concerns. Rooms A1, A2, A3, A4, A5, A6, A7, A8, A9, and A10 had black spots around the air vents in the showers, holes in the walls, missing baseboards non-working lights, and showers not working properly. Rooms B10 had mold identified in the room and B11 was used for storage. Rooms C12, C14, C15, C16, C17, C18, C19, C19, C20, C21, and C22 had black spots in, no light in bathrooms or light covers, holes in the wall, missing tiles on the floor, holes in the walls, black buildup in showers, and baseboards missing. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents had the right to a safe clean comfortable and homelike environment for 5 of 10 residents (Resident #5, #6, #7, #8, #9, and #10) reviewed for environmental concerns. Resident #5 And Resident #6 had a black substance in their rooms that the families felt were suspicious of being mold. Resident #6, # 7, #8, #9, and #10's rooms had broken lights, holes in their walls, broken showers and maintenance issues that were not addressed. The facility failure could cause residents to have safety concerns.

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 and permitted only authorized personnel to have access to 1 of 3 rooms (DON's office) used for storage of drugs and biologicals. The facility failed to ensure the DON's office door and the metal filing cabinet where discontinued narcotics were stored, was at all times secured under double lock, and unable to be accessed by unauthorized personnel. This failure could place residents at risk for misuse of medication and overdose, drug diversions, and adverse reactions to medications.

Inspectors wroteBased on record review and interview, the facility, with a capacity of more than 120 beds or more less, failed to employ a qualified social worker for the facility reviewed for administration in that: The facility did not have a qualified social worker since [DATE]. This failure could affect any residents in need of social services and place them at risk of psycho-social decline and poor-quality of life.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to provide maintenance and housekeeping services for 2 (Resident #13 and #54) of 10 resident rooms observed for safe, homelike and sanitary environment. The facility failed to ensure missing and damaged laminate flooring panels were replaced in Resident #13's room (216-B). The facility failed to ensure missing baseboards were replaced in Resident #54's bedroom (#207-B) and bathroom; repair the vanity drawer in the bathroom; clean the toilet and remove trash from the floor of bathroom. These failures could place residents at risk for psychosocial harm and a diminished quality of life and an unsanitary environment.

Inspectors wroteBased on observations, interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan for each resident that included measurable objectives and time frames to meet a resident's medical, nursing, and mental and psychosocial needs for 1 of 4 residents (Resident #72) reviewed for care plans. The facility failed to ensure Resident #72's comprehensive care plan reflected her positive PASRR Evaluation and the recommended services. The facility failed to ensure Resident #72's comprehensive care plan addressed her smoking status. These failures could place residents at risk for not receiving needed care and services, including care and services to prevent injury.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was provided adequate supervision and preventative measure to prevent injuries for 1 of 4 residents (Resident #72) reviewed for accident hazards. The facility failed to follow the facility's policy to assess Resident #72 for safety when smoking. This failure could place residents at risk for accidents and injuries due to failure to evaluate for risk.

Inspectors wroteBased on observation, record review, and interview the facility failed to have an ongoing and effective pest control program for 1 of 1 building reviewed for pest control. The facility did not have an effective pest control program to eradicate the cockroaches in the facility. The facility failure placed residents at risk for diarrhea, dysentery (infectious diarrhea), salmonella (an infection that can lead to diarrhea, fever, and stomach cramps), and other serious health concerns.

Inspectors wroteBased on interview and record review the facility failed to provide pharmaceutical services, including the accurate acquiring, administering and receipt of all drugs and biologicals, to meet the needs of 1 of 4 (Resident #2) residents reviewed for pharmacy services. The facility failed to ensure Resident #2 was administered his Ambien (a medication to treat insomnia) for 3 days while he was admitted to the facility for respite care. This failure could place residents who receive medications at risk of not receiving the intended therapeutic benefit of the medications.

Inspectors wroteBased on interview and record review the facility failed to ensure laboratory services were obtained to meet the needs for 1 of 5 (Resident #1) residents reviewed for laboratory services. The facility did not ensure Resident #1 had a CBC (complete blood count-used to look at overall health and find a wide range of conditions including anemia (condition in which the blood does not have enough healthy red blood cells) and infection) and CMP (complete metabolic panel-test that checks the body's fluid balance and levels of electrolytes) lab tests every 6 months as ordered. This failure could place the residents at risk of not receiving lab services as ordered and suffering from an undetected infection, decreased electrolyte balances, dehydration, and decreased kidney function.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide each resident with a nourishing, well-balanced diet that meets his or her daily nutritional and special dietary needs, taking into consideration the preferences of each resident for 1 of 3 (Resident #3) residents reviewed for diets. The facility failed to ensure Resident #3 received his health shake or double meat portion at lunch on 4/16/24. This failure could place resident at risk for weight loss, altered nutritional status and diminished quality of life.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure honey thickened liquids were prepared in a form designed to meet individual needs for 1 of 3 residents (Resident #3) reviewed for food form and preparation. The facility failed to ensure Resident #3 received honey thickened liquids with his lunch meal on 4/16/24 and 4/17/24. This failure could place residents who received thickened liquids at risk of consuming liquids that could cause choking and aspiration (when something you swallow goes down the wrong way and enters your airway).

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The facility did not ensure dietary staff had their hair restrained while in the kitchen. These failures could place residents at risk of cross-contamination and foodborne illness.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, sanitary, and comfortable environment for residents, staff and the public for 1 of 1 building reviewed for physical environment. 1. The facility did not ensure the door to the dining room was not damaged and had thick plastic peeling off it. 2. The facility did not ensure the bathroom in room [ROOM NUMBER] did not have tiles that had fallen off the wall, wallpaper peeling off the wall, the baseboard warped, and a drawer to the vanity with the face peeling off. This failure could place all residents at risk for an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on record review and interview, the facility, with a capacity of more than 120 beds or less, failed to employ a qualified social worker for the facility reviewed for administration in that: The facility did not have a qualified social worker since 11/6/2023. This failure could affect any residents in need of social services and place them at risk of psycho-social decline and poor-quality of life.

Inspectors wroteBased on interview and observation the facility failed to ensure the residents had the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service for 8 of 8 residents (Residents #33, #40, #47, #53, #80, #82, #85 and #405) reviewed for rights to forms of communication. The facility did not implement a system for delivering mail on Saturday. This failure could place the residents at risk of not receiving mail in a timely manner and a diminished quality of life.

Inspectors wroteBased on observation, interview and record review the facility failed to provide, based on the comprehensive assessment and care plan and the preferences of each resident, an ongoing program to support residents in their choice of activities, both facility-sponsored group and individual activities and independent activities designed to meet the interests of and support the physical, mental, and psychosocial well-being of 1 of 4 halls (Tradition Hall locked unit) reviewed for activities The facility failed to ensure there were organized activities provided to the residents during scheduled activity time. This failure could place residents at risk for a diminished quality of life, isolation, boredom, lack of stimulation, and a decline in mental status.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who need respiratory care was provided such care, consistent with professional standards of practice, for 1 of 3 residents (Resident #251) reviewed for respiratory care. 1. The facility failed to ensure Resident #251's O2 tubing was covered and labeled. 2. The facility failed to ensure Resident #251's nebulizer tubing was covered. 3. The facility failed to ensure Resident #251's BiPAP tubing was clean and covered. 4. The facility failed to ensure Resident #251's O2 Humidifier bottle was dated and not empty. These failures could affect residents who were dependent on respiratory care and could contribute to upper respiratory infections and worsening of their physical condition.

Inspectors wroteBased on interview and record review, the facility failed to coordinate the assessment of 1 of 4 residents (Resident #90) reviewed for the pre-admission screening and resident review (PASRR) program and PASRR assessments and evaluations. The facility failed to ensure Residents #90 had an accurate PASRR Level 1 Screening which indicated diagnoses of mental illness. This failure could affect residents with psychiatric diagnoses who may not be evaluated for PASRR services and place them at risk of not receiving services for care and treatment.