Avir at San Angelo

Inspectors wroteBased on interview and record review, the facility failed to ensure the Pre-admission Screening and Resident Review (PASRR) Level I assessment accurately reflected the resident's status for one (Resident #21) of three residents reviewed for PASRR Level 1 screenings. The facility failed to refer Resident #21 to the State-designated authority for a PASRR Level II review when she was admitted with a diagnosis of schizophrenia and a PASRR Level 1 positive for mental illness. This failure could place residents with mental illness at risk of not receiving a PASRR Evaluation, individualized care, or special services to meet their needsFindings include: A record review of Resident #21's face sheet, dated 5/7/2026, revealed a [AGE] year-old female who was admitted to the facility on [DATE]. [...]

Inspectors wroteBased on observations, interview, and record review, the facility failed to ensure the resident environment remained as free of accident hazards as was possible and each resident received adequate supervision and assistance devices to prevent accidents for one of three residents (Resident #11) and 9 of 47 sharps containers reviewed for accidents and hazards. The facility failed to ensure bed alarm was plugged in while Resident #11 was in bed as indicated on his current comprehensive care plan and current physician's orders. The facility failed to ensure sharps containers were replaced when full in 9 rooms (Rooms: 105, 106, 108, 109, 111, 113, 207, 210, and 401). The failures could place residents at risk for injury.

Inspectors wroteBased on observations, interviews, and record reviews, 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. 1. The facility failed to ensure stored foods were properly stored, labeled, and dated.2. The facility failed to ensure prepared food was discarded after 72 hours (3 days) per facility policy. 3. The facility failed to prevent cross-contamination of food items when pureeing food.4. The facility failed to ensure personal food items were not stored in 1 of 2 of the kitchen refrigerators. 5. The facility failed to ensure the dietary staff wore beard covers while in the kitchen. These failures could place residents who received prepared meals from the kitchen at risk of food borne illness and cross-contamination.

Inspectors wroteBased on observations, interviews and record review the facility failed to dispose of garbage and refuse properly for 1 of 2 dumpsters reviewed for environment. The facility failed to ensure garbage was placed in a covered dumpster. These failure could affect residents by placing them at risk of illnesses, or be provided an unsafe, unsanitary, and uncomfortable environment.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement a comprehensive person-centered care plan that included measurable objectives and time frames to meet a resident's medical and nursing needs and describe the services to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 2 (Resident #23, and Resident #42) of 12 residents reviewed for care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #23 for ADL dependence and means to address psychosocial needsThe facility failed to develop a comprehensive person-centered care plan regarding hospice services for Resident #42. This deficient practice could place residents in the facility at risk of not receiving the necessary care or services.

Inspectors wroteBased on observations, interviews, and record review, the facility failed to ensure that residents who are 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 2 residents (Resident #8) reviewed for trauma-informed care. The facility failed to ensure Resident #8 had a trauma screening completed upon admission to the facility that identified possible triggers when Resident #8 had a history of trauma. This failure could place residents at an increased risk for psychological distress due to re-traumatization.

Inspectors wroteBased on observations, interviews and record review the facility failed to ensure a medication error rate of less than 5%, and the medication error rate was 7.14% with 2 errors in 28 opportunities involving 1 staff (LVN D) and 1 resident (Resident #3) reviewed for medication pass. LVN D did not fully administer the crushed medications to Resident #3 via PEG tube. (Percutaneous Endoscopic Gastrostomy, a medical procedure used to insert a feeding tube directly into the stomach through the abdominal wall.) This failure could place residents at risk of not receiving their medications as prescribed according to physician's orders and facility policy and procedures.

Inspectors wroteBased on observation, interview, and record review the facility failed to store all drugs and biologicals in locked compartments for 1 of 4 (hall 2 cart) observed for medication storage and security. MA C failed to ensure her medication cart was secured when it was left unattended on 05/05/2026. These failures could place clients at risk for drug diversion or accidental ingestion.

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 to help prevent the development and transmission of communicable diseases and infections for 1 (Resident #37) of 3 residents reviewed for infection control. CNA A failed to change her gloves after they became contaminated while assisting Resident #37 with incontinent care. This failure could place residents' risk for cross contamination and the spread of infection.

Inspectors wroteBased on interview and record reviews, the facility failed to ensure residents with pressure ulcers receive necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new ulcers from developing for 1 (Resident #1) of 4 residents reviewed for pressure ulcers. The facility failed to obtain treatment orders for wound care upon admission for Resident #1. This failure could place residents at risk of improper wound management, the development of new pressure injuries, deterioration in existing pressure injuries, infection, and pain.

Inspectors wroteBased on interview and record review 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, attain, and/or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 3 of 12 (Residents #1, #2, and #3) residents reviewed for comprehensive care plans. The facility failed to have a care plan for Resident #1's dialysis, diabetic care, glaucoma, seizures, mental health needs, wound care, blood pressure monitoring, ADL assistance, and vaccine status. The facility failed to have a care plan for Resident #2's mental health and behavioral issues, pain, high blood pressure, hospice services, ADL needs, communication, cognitive status, nutritional status, risk to skin impairment, incontinence, or vaccination status. [...]

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents for 2 of 5 residents (Resident #2 and Resident # 3) reviewed for accident and hazards: The facility failed to implement care planned anti-slip strips on the floor in front of Resident # 2's recliner. The facility failed to implement care planned [NAME] sheet (anti-slip device) in Resident #3's wheelchair. This failure could place residents at risk of a diminished quality of life leading to a variety of emotional and physical problems/issues because of accident hazards.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist the residents in making appointments to ensure residents receive proper treatment and assistive devices to maintain hearing abilities for one of two residents (Resident #45) reviewed for hearing devices. The facility failed to make an appointment for an audiologist for Resident #45 after the Responsible Party requested one on 8/20/24. This failure could place residents at risk of decreased communication ability, quality of life, and/or social isolation.

Inspectors wroteBased on observation, interview and record review, the facility failed to assist the residents in making appointments to ensure residents receive proper treatment and assistive devices to maintain hearing abilities for one of two residents (Resident #45) reviewed for hearing devices. The facility failed to make an appointment for an audiologist for Resident #45 after the Responsible Party requested one on 8/20/24. This failure could place residents at risk of decreased communication ability, quality of life, and/or social isolation.

Inspectors wroteBased on observation and interview the facility failed to maintain all mechanical, electrical, and patient care equipment in safe operating condition for 1 of 1 kitchen reviewed for physical environment. The facility failed to ensure one of six stove top burners ignited automatically. This failure could place residents at risk of foodborne illnesses and potential for injury to residents and staff.

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 to help prevent the development and transmission of communicable diseases and infections for 3 (Residents #14 and #28 and #288) of 4 residents reviewed for infection control in that: CNA F failed to wash her hands and change her gloves after they became contaminated during incontinent care while assisting Resident #14. CNA D used double gloves when she performed incontinent care for Resident #28. RN K failed to wash her hands and change her gloves after they became contaminated during wound care performed on Resident #288. These failures could place resident's risk for cross contamination and the spread of infection.

Inspectors wroteBased on Observation, interview and record review the facility failed to ensure the resident the right to receive written notice, including the reason for the change, before the resident's room or roommate in the facility is changed for 1 0f 4 residents (Resident #1) reviewed for resident rights. Transfer and the reason for the transfer before the roommate was changed. Based on interview and record review the facility failed to ensure residents legal guardian had 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 option he or she preferred for 1 of 1 resident (Resident #60) reviewed for resident rights. [...]

Inspectors wroteBased on interview, and record review the facility failed to ensure Residents were free from abuse a 1 of 6 residents (Resident #1) reviewed for abuse. 1. The facility to protect Resident #1 from Resident #2 pouring water on Resident #1 when he annoyed him. The deficient practices could affect any resident and contribute to further abuse or neglect.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure all alleged violations involving abuse are reported immediately to the Administrator of the facility for 1 of 6 residents (Resident #1) reviewed for abuse. 1. CNA B failed to immediately report her suspicions of abuse when she found Resident #1 Wet . The deficient practices could affect any resident and contribute to further abuse or neglect.

Inspectors wroteBased on observations, interview, and record review, the facility failed to maintain an environment that was free from accidents and hazards for 31 (All resident on 100 Hall) of which 5 of 31 (Resident #81,82, 20, 40, and 77) had cognitive decline that could still access their sinks, of 90 residents. -Temperature readings for the public restroom on the 100 hall were 128 degrees Fahrenheit. -The temperature reading in the restroom to Resident room [ROOM NUMBER] on the 100 hall was 128 degrees Fahrenheit. -5 residents on the 100 hall had cognitive decline and could access their sinks. An Immediate Jeopardy to residents' health or safety was identified on 12/21/23. The Immediate Jeopardy template was provided to Administrator on 12/21/23 at 7:23PM. [...]

Inspectors wroteBased on interview and record review the facility failed to review the work of each Certified Nurse Assistant (CNA) at least once every 12 months, for 4 (CNA A, CNA B, CNA C and CNA D) of 4 CNAs reviewed for annual competency evaluations (there were only 4 CNAs that had worked at the facility longer than a year). This deficient practice could affect 90 residents and place them at risk of not receiving consistent, appropriate interventions necessary to meet the residents' needs.

Inspectors wroteBased on interviews and record reviews, the facility failed to develop and implement an infection prevention and control program to include antibiotic use protocols and a system to monitor antibiotic use for 1 of 1 facility reviewed for antibiotic stewardship. The facility failed to utilize an antibiotic tracking log for the months of September 2023 through December 2023. This failure could place residents at risk for inappropriate antibiotic use.

Inspectors wroteBased on observation, interview and record review, the facility failed to promote care in a manner that maintained and enhanced each resident's right to a dignified existence dignity and respect for 2 (Resident #'s 54 and 75) of 22 residents reviewed for dignity. The facility failed to ensure Resident #54 was properly dressed and, in his wheelchair, when assisted to and from the shower room to take a shower. The facility failed to ensure that resident #75 was provided privacy when her finger stick blood sugar was taken in the dining room before her lunch. These failures placed residents at risk of not being provided care and services in a respectful and dignified manner that could result in a loss of the resident's self-esteem and quality of life.

Inspectors wroteBased on interview and record review the facility failed to provide both a Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage (Form CMS-10055) and a Notice of Medicare Non-coverage (Form CMS-10123 general notice) for 2 of 3 residents (Residents #3 and #83) reviewed for Medicare Beneficiary Protection Notification when discharged from Medicare Part A Services with benefit days remaining. 1. The facility failed to ensure Resident #3's representative was given a NOMNC (Form CMS-10123 general notice) and a SNF ABN (Form CMS-10055) when he was discharged from skilled services. 2. The facility failed to ensure Resident #83's representatiive was given a NOMNC form and a SNF ABN form when she was discharged from skilled services. These failures could place residents and their representatives at risk of not being fully informed about services covered by Medicare.

Inspectors wroteBased on interview and record review, the facility failed to ensure a summary of the baseline care plan was provided to the resident and their representative for 2 of 7 residents (Resident #s 89 and 349) reviewed for baseline care plans following admission into the facility for skilled nursing care services, in that: 1. Resident #89's had baseline care plans dated 11/17/23 and 11/27/23, and a summary had not been provided to her or her representative. 2. Resident #349's baseline care plan was dated 12/14/23 and a summary had not been provided to him. This failure placed the residents at risk for not receiving information regarding the care and services to be provided to meet their needs and to promote their physical and mental health and well-being within their new living environment.

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that residents who were unable to conduct activities of daily living received the necessary services to maintain good personal hygiene for 3 of 26 residents (Resident's #3, #34, #54), reviewed for activities of daily living. -The facility failed to provide nail care for Resident #3. -The facility failed to provide oral care for Resident #3, #34 and #54. These failures could place residents who were dependent on staff for ADL care at risk for loss of dignity, risk for infections, skin breakdown, dental pain and cavities, and a decreased quality of life.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals, and preferences for 2 of 4 residents (Resident #3 and Resident #88) reviewed for respiratory care. A. Resident #3's and #88's nebulizer mask and tubing were not kept in a plastic bag when not in use. B. Resident #3's oxygen cannula and tubing were not kept in a plastic bag when not in use. This failure could place residents requiring oxygen at risk for respiratory infections due to the potential for microorganisms infiltrating their oxygen, nebulizer equipment and supplies causing a decline in physical health. The findings Included: [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure that drugs and biologicals used in the facility were secured and stored in accordance with currently accepted professional principles for 1 of 4 med carts reviewed. -The 300-hall medication cart was left unlocked. -CMA E left Resident #32's medication in a pill cup on her bedside table unattended. This failure could place residents who receive medications in the facility and place them at risk of receiving incorrect medications or ineffective therapeutic doses or drug diversion.

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, in that: 1. Opened food items were not placed in sealed containers and were not fully dated. 2. Floors and walls throughout the dietary department were soiled with food, grease, dust. 3. Shelf units were soiled with spilled spices, food, and had rusting surfaces. 4. The microwave oven and electric mixer were soiled with splattered food. 5. The low temperature dish machine did not have water temperatures and sanitizer levels consistently documented. 6. Cooking utensils and pans were stored with their sanitized surfaces exposed to contaminants in the air. 7. Ceiling air duct vent covers were soiled with dust build-up. [...]

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 to help prevent the development and transmission of communicable diseases and infections for 2 of 2 residents (Resident #'s 3 and 183) reviewed for infection control practices, in that: -LVN G failed to disinfect her glucometer between residents when doing fingerstick blood sugars. -LVN G failed to perform hand hygiene after glove changes and between residents when doing fingerstick blood sugars. These failures could place residents at risk for the spread of infection.

Inspectors wroteBased on interview and record review, the facility failed to coordinate the assessment of one (Resident #72) of two residents with the pre-admission screening and resident review (PASRR) program. The facility did not identify Resident #72 as having a newly evident mental illness with a primary diagnosis of dementia after she acquired a new diagnosis that would require a new PASRR Level 1 (PL1) form or PASSR 1012 form be completed. 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.

Inspectors wroteBased on observation, interview and record review the facility failed to develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights, which included measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that were identified in the comprehensive assessment and described the services that were to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being for 1 of 8 residents (Resident #45) reviewed for comprehensive care plans. The facility failed to develop a comprehensive person-centered care plan for Resident #45 after the resident was admitted with an order for oxygen. [...]

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free of any significant medication errors for 1 of 4 residents (Resident #1) reviewed for significant medication errors. The facility failed to ensure Resident #1 received the correct prescribed seizure medication Carbamazepine, which resulted in the resident having a seizure and was transferred to the hospital. Resident #1 missed 6 doses of the medication from 08/11/23 through 08/13/23. This failure resulted in actual harm to Resident #1 on 08/14/23. The noncompliance was determined to be past noncompliance (PNC). The noncompliance began on 08/11/23 and ended on 08/14/23. The facility had implemented the actions that corrected the noncompliance before the surveyor's entrance to the facility on [DATE]. [...]

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 to help prevent the development and transmission of communicable disease and infections for one (Resident #2) of two residents reviewed for infection control practices. CNA H failed to perform proper hand hygiene and glove changes while providing incontinence care to Resident #2. This failure could place residents at risk for the spread of infection.