Avir at Richland Hills

Inspectors wroteBased on observations, interviews, and record review, the facility failed to adequately equip residents the ability to call for staff assistance through a communication system, which relays the call directly to a staff member or to a centralized staff work area, from the bedroom of 3 of (Resident #1, Resident #2 and Resident #3) 7 resident rooms reviewed for resident call systems. The facility failed to ensure the call light in the room and bathroom were operable for Resident #1, Resident #2 and Resident #3. This failure could place residents at risk of being unable to have a means of directly contacting caregivers which could place them at risk for injuries and unmet needs.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure the right to reside and receive services in the facility with reasonable accommodation of resident needs and preferences for two (Resident #12 and Resident #13) of ten residents reviewed for reasonable accommodation of needs. The facility failed to ensure the call light system in Resident #12 and Resident #13's rooms were in a position that was accessible to the residents on 02/03/2026. This failure could place the residents at risk of being unable to obtain assistance when needed and help in the event of an emergency.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure that residents' environment remained free of hazards as was possible for one (Resident #9) of ten residents and one (LVN A) of three LVNs reviewed for accident hazard. The facility failed to ensure Resident #9 did not have a can of Off insect spray on his bedside table on 02/03/2026. The facility failed to ensure LVN A did not leave a container of germicidal wipes (cleaning wipes designed to eliminate bacteria, viruses, and fungi) on top of her cart on 02/03/2026. These failures could prevent the residents from having an environment that was free from toxic chemicals.

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that a resident who needed respiratory care, was provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, and the residents' goals and preferences for one (Resident #4) of eight residents reviewed for respiratory care. The facility failed to ensure Resident #4's BiPAP (noninvasive ventilation that helps you breathe) face mask and oxygen tubing were stored in a bag when not in use on 02/03/2026. This failure could place residents at risk for respiratory infection and not having their respiratory needs met.

Inspectors wroteBased on observation, interview and record review the facility failed to, in accordance with State and Federal laws, store all drugs and biologicals in locked compartments under proper temperature controls, and permitted only authorized personnel to have access to the keys for two (Residents #11 and Resident #14) of ten residents reviewed for medication storage. 1. The facility failed to ensure that Resident #11's pain relieving spray was not on top of the resident's drawer on 02/03/2026.2. The facility failed to ensure that Resident #14's pain reliving roll-on was not on top of the resident's overbed table on 02/023/2026. These failures could place the residents at risk of misuse of medications and possible adverse reactionsFindings included: 1. Record review of Resident #11's Face Sheet, dated 02/03/2026, reflected a [AGE] year-old male who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure the nurse call system was assessable for one (Resident #7) of twelve residents reviewed for resident call system. The facility failed to ensure the call light system in Resident #7's room was functioning on 02/03/2026. This failure could place the residents at risk of not being able to directly contact the staff to obtain assistance for activities of daily living or help in an event of an emergency.

Inspectors wroteBased on interviews and record reviews, the facility failed to coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort for two of five residents (Resident #7 and Resident #25) reviewed for pre-admission screening and resident review (PASARR) assessments. 1. Resident #7's PASRR Level I indicated he did not have a diagnosis of mental illness despite having a diagnosis of mental illness and the facility failed to ensure Resident #7 received a PASRR Level II Screening. 2. Resident #25's PASRR Level I indicated he did not have a diagnosis of mental illness despite having a diagnosis of mental illness and the facility failed to ensure Resident #25received a PASRR Level II Screening. [...]

Inspectors wroteBased on observations, interviews and record review, the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food service safety in the facility's only kitchen. The Dietary Aide failed to wear a beard restraint while working in the kitchen. This failure could affect the residents who receive their meals from the facility's only kitchen by placing them at risk for food contamination. Observation on 12/03/2025 at 11:12 AM revealed the dietary aide was not wearing a beard restraint while working in the kitchen. Observation and interview on 12/04/2025 at 11:01 AM revealed the dietary aide was wearing a beard restraint, but it was underneath his chin and not covering his beard and mustache. The dietary aide stated he was wearing a beard restraint yesterday (12/03/25), but he must have forgotten to put it back at some point. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the resident call light system was maintained within reach for 2 of 5 residents (Resident #7, and Resident #28) reviewed for call light system access. The facility failed to maintain Resident #7 and #28's call light system in working order. The call light in their shared room had detached completely from the wall, rendering it unusable. This failure could place residents at risk for delayed assistance and an inability to request help when needed.

Inspectors wroteBased on observations, interviews, and record review the facility failed to establish and maintain an infection prevention and control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infections for 1 Resident of 3 (Resident#1), reviewed for infection control. The facility failed to ensure that CNA A performed hand hygiene before providing peri care. The facility failed to ensure that CNA A provided perineal care according to professional standards of practice when she cleaned a female resident (Resident#1) perineal area from back to front, rather than from front to back which is consistent with professional standards. This failure could cause residents the risk of urinary tract infections and compromise their health and safety.

Inspectors wroteBased on observation and interview, the facility failed to provide a safe, comfortable, and homelike environment, for daily living for three (Resident#1 room, Resident#2 room and Resident# 3 room) of sixteen resident rooms reviewed for environmental concerns. The facility failed to maintain Resident#1, Resident#2 and Resident#3 room at temperatures levels ranging of 71 F to 81 F. This failure could put residents at potential risk associated with temperature extremes, like hypothermia or overheating.

Inspectors wroteBased on observation, interview, and record review the facility failed to provide a safe, functional, sanitary, comfortable, and homelike environment for one (100 Hall) of two halls and two (room [ROOM NUMBER] and room [ROOM NUMBER]) of six rooms reviewed for decent living environment. 1. 100 Hall had a leak from the ceiling tile opening, with a trashcan and bucket in the middle of the hallway floor to catch the water. 2. room [ROOM NUMBER] had a socket hanging from the wall. 3. room [ROOM NUMBER] light switch in the bathroom was not fully covered. These failures could result in a resident's diminished quality of life due to an unsafe environment that is not homelike. Findings Included:In an observation and interview on 07/22/25 at 10:05 AM, reflected a half covered light switch in the bathroom of room [ROOM NUMBER]. [...]

Inspectors wroteBased on observations, interviews, and record review, the facility failed to store, prepare, distribute, and serve food in accordance with professional standards for food service safety in 1 of 1 kitchen reviewed for kitchen sanitation. The facility failed to ensure food was properly stored in the facility's kitchen. The facility failed to ensure food on the steam table reached the appropriate temperature before plating food for resident consumption. This failure could place residents at risk for food-borne illness. Findings Included: Observation of the facility's refrigerator on 09/08/24 beginning at 9:20 AM revealed: - 6 cucumbers with fuzzy white spots; - 3 cut tomatoes in a box open and exposed to air; - 1 onion with black spots; - 7 withered tomatoes; - 1 bag of shredded lettuce with brown lettuce leaves; - 1 bucket of pork chops thawing on the second shelf above eggs; [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to provide the necessary services for residents who are unable to carry out activities of daily living to maintain good grooming and personal hygiene for one of thirteen resident (Resident # 74) reviewed for ADLs. The facility failed to provide Resident #74 with ADL care (incontinent care). This deficient practice could place residents who required extensive assistance with ADLs at risk of not receiving care and services needed to maintain quality of life and prevent decline in their mental and psychological wellbeing.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure a resident receives care, consistent with professional standards of practice, to prevent pressure ulcers and does not develop pressure ulcers unless the individual's clinical condition demonstrates that they were unavoidable for 1(Resident #67) of 3 residents reviewed for pressure ulcers. The facility failed to prevent the development of a pressure ulcer for Resident #67. This failure placed residents at risk of delayed identification/treatment of injuries, worsening of injuries, pain, and infection. Findings Include: Record review of Resident #67's face sheet dated 09/10/24 revealed, an [AGE] year-old female who admitted to the facility originally on 01/05/23 and readmitted on [DATE] with the following diagnoses which included; [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to protect the confidentiality of personal health care information for two of six (Resident #6 and Resident #65) residents reviewed for confidentiality of records. The facility failed to ensure LVN F locked and closed the laptop during a medication pass, which exposed Resident #6's personal information to include some of his medication orders. The facility failed to ensure LVN A locked the computer prior to leaving the Nurse's Station, which exposed Resident #65's personal information to include some of her diagnoses. This failure could affect residents by placing them at risk for loss of privacy and dignity.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident received assistance devices to prevent accidents for 1 (Resident #19) of 2 Residents who were observed for transfers. LVN A failed to use the gait belt as needed due to the resident having unsteady gait while repositioning Resident #19 in the wheelchair. The deficient practices could affect residents who require assistive devices during transfers and could contribute to avoidable falls.

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 1(Resident #74) of 8 residents reviewed for infection control in that; During a wound dressing change for Resident #74, LVN C did not sanitize her hands or change gloves in between removal of an old dressing and cleansing and application of a new dressing. The deficient practices could place residents at-risk for infection due to improper care practices. Findings Included: Record review of Resident #74's face sheet revealed she was [AGE] year-old female admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to ensure residents received adequate supervision and assistive devices to prevent accidents for one of seven residents (Resident #1) reviewed for supervision. The facility failed to ensure Resident #1 was adequately supervised in order to prevent her from eloping from the facility. Resident #1 first eloped from the facility on 12/19/23. As a result of the elopement, she was placed on the secured unit at the facility. However, the facility continued to fail to provide adequate supervision and Resident #1 eloped from the facility for the second time on 05/04/24. An Immediate Jeopardy (IJ) was identified on 07/24/24 at 4:19PM. The IJ template was provided to the facility on [DATE] at 4:45PM and signed by Administrator A. [...]

Inspectors wroteBased on interview and record review the facility failed to immediately notify, consistent with his or her authority, the resident representative(s) when there was a significant change in the resident's physical, mental, or psychosocial status for 1 (Resident #2) of 5 residents reviewed for notification of changes. The facility failed to notify Resident #2's designated emergency contact [Family Member] when he developed altered mental status and sustained a head injury while nearly falling out of bed. This failure could place residents at risk of their responsible parties not being notified or involved in their plan of care.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure residents in the facility were free from neglect for 1 (Resident #2) of 5 residents reviewed for neglect. LVN Q failed to document the assessment and treatment she performed on Resident #2. LVN Q failed to perform any additional assessments of the resident's injury and notify any other staff of the injury. These failures placed residents at risk of pain, diminished quality of life, delayed diagnosis, treatment, and serious physical harm.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care was provided such care, consistent with professional standards of practice for 3 residents (Residents #19, #24, and #47) of 3 residents reviewed for oxygen. The facility failed to ensure Residents #19, #24 and #47 had orders for oxygen administration. This failure placed residents who received oxygen therapy at risk for inadequate or inappropriate amounts of oxygen delivery and ineffective treatment.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the medication error rate was not five percent (5%) or greater for one of two staff (LVN F and LVN G) which resulted in a 45.16% medication error rate after 31 opportunities with 14 errors for three of six residents (Residents #32, Resident #42, and Resident #8) reviewed for medications. 1. LVN F crushed all medications together and mixed them on one cup of pudding without an order to mix the medications together for Resident #32. 2. LVN G failed to follow the physician orders for flushing Resident #42's gastrostomy tube with 5-10 mL (or prescribed amount) of water before, between, and after medications, when she administered medication. 3. LVN G removed Resident #8's patch and immediately placed another one on without allowing 12 hours for rest after removal. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the interdisciplinary team determined self-administration of medication was safe for 1(Resident # 43) of 1 resident reviewed for medication self-administration. The facility failed to prevent Resident #43 from possessing and administering four prescribed eye drops and an inhaler without an assessment to determine if he could safely self-administer the medication. This failure could place all residents who self-administered medications at risk of not receiving the therapeutic dose of their medication as ordered.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments and assure only authorized personnel to have access to the keys for 1 resident (Resident #43) of 8 residents reviewed for pharmacy services, in that: The facility failed to ensure that Resident #43's prescribed eye drops and albuterol inhaler was stored in a secured place. This failure could place all residents on the 200 Hall North at risk of drug diversion or misuse of medications.