Avir at San Augustine

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure a medication error rate of less than 5 percent. The facility had a medication error rate of 21.62%, based on 8 errors out of 37 opportunities, involving 3 of 5 (Resident #16, Resident #19 and Resident #39) residents and 1 of 2 nurses (LVN B) reviewed for medication errors. LVN B failed to administer scheduled medications on 5/12/2026 to Resident #16 and Resident #39 and failed administer the correct dosage of medications on 5/12/2026 to Resident #16 and Resident #19. These failures could place residents at risk of not receiving the intended therapeutic benefits of their medications. [...]

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 3 of 5 staff (LVN B, the Treatment Nurse, and CNA D) reviewed for infection control. The facility failed to ensure the LVN B sanitized or washed hands between glove changes when colostomy care was provided to Resident #8 on 5/11/2026. The facility failed to ensure the Treatment Nurse sanitized or washed hands between glove changes when wound care was provided to Resident #8 on 5/11/2026. The facility failed to ensure CNA D washed or sanitized hands while passing lunch trays on 5/11/2026 on Hall 200. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure that a resident who is incontinent of bladder receives appropriate treatment and services to prevent infections and to restore continence to the extent possible for 1 of 3 (Resident #36) residents observed for urinary catheter (tube placed in the bladder that drains into a bag outside of the body) care. The facility failed to ensure the urinary drainage bag was kept off the floor for Resident #36 on 5/11/26. This failure could place residents at risk for bacterial infections from improper catheter care.

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 8 residents (Resident #5 and #20) and 4 of 8 staff (CNA A, CNA B, LVN C and LVN D) reviewed for infection control. The facility failed to ensure CNA A and CNA B followed enhanced barrier precautions when providing care to Resident #5 on 3/03/2025. The facility failed to ensure LVN C and LVN D followed enhanced barrier precautions when providing care to Resident #20 on 3/04/2025. This failure could place residents at risk for cross contamination and infection.

Inspectors wroteBased on observation, interview, and record review, the facility failed to provide a safe, clean, and sanitary environment for 1 of 1 dining room (main dining room) and resident room [ROOM NUMBER]. 1. The facility failed to clean the main dining room ceiling fans (4) and vents (4). 2. The facility failed to maintain sheetrock and paint on the dining room walls and ceiling. 3. The facility failed to repair 3 obstructed/fogged windows in the main dining room. 4. The facility failed to repair a missing tile and broken floor tile in room [ROOM NUMBER]. These failures could place residents at risk for exposure to an unclean, unsanitary environment, risk of falls and other injuries due to an unsafe 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 1 smoking area reviewed for smoking safety. The facility failed to ensure cigarette butts were not discarded into the regular trash can along with flammable products on 3/3/35 and 3/4/25. This failure could place residents at risk of injury, burns, and an unsafe smoking environment.

Inspectors wroteBased on observations, interviews, and record reviews, the facility failed to treat residents with respect and dignity and care for them in a manner and in an environment that promoted maintenance or enhancement of their quality of life for 1 of 8 residents (Resident #34) reviewed for resident rights. The facility failed to ensure CNA A provided privacy to Resident #34 when providing incontinent care on 3/04/2025. This failure could place residents at risk for decreased quality of life, decreased self-esteem and increased anxiety.

Inspectors wroteBased on interview and record review, the facility failed to ensure the drug regimen review recommendation from the pharmacy consultant were acted upon for 2 of 4 residents reviewed for drug regimen review. (Residents #23 and Resident #253) -The facility did not follow up on the pharmacy consultant's recommendations dated 11/08/24 with the physician for Residents #23 and #253. -The facility did not develop policies and procedures to address the timelines of the MRR. These failures could place residents being at risk for medication errors, unnecessary medications, and incorrect administration.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure a resident who needs respiratory care, including tracheostomy care, is provided such care consistent with professional standards of practice for 1 of 7 residents (Resident #1) reviewed for respiratory care. The facility failed to ensure that Resident # 1 received monitoring during respiratory treatments while experiencing anxiety/nervous-type behaviors on 2/5/25. Resident #1 found in distress with no pulse with ventilator partially disconnected. The resident died on 2/8/25. An Immediate Jeopardy (IJ) was identified on 2/13/25. The IJ template was provided to the facility on 2/13/25 at 5:00 pm. [...]

Inspectors wroteBased on observation, interview and record review the facility failed to ensure residents were free of significant medication errors for 1 of 8 residents (Resident #246) reviewed for significant medication errors. The facility failed to ensure Resident #246 was free of significant medication errors when 11 extra doses of potassium 40 mEq were administered from [DATE] to [DATE] resulting in Resident #246 requiring hospitalization. The noncompliance was identified as PNC (past non-compliance). The IJ (immediate jeopardy) began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk of not receiving the therapeutic effect of their medications as ordered by the physician.

Inspectors wroteBased on interview and record review the facility failed to provide or obtain laboratory services, to meet the needs of its residents for 1 of 8 residents (Resident #246) reviewed for laboratory services. The facility failed to obtain the ordered lab (comprehensive metabolic panel) for Resident #246 on [DATE] and [DATE] when the ADON failed to notify the lab of the new orders and note the lab orders on the 24-hour report on [DATE], resulting in Resident #246 requiring hospitalization for critically high potassium level of 7.6 on [DATE]. The noncompliance was identified as PNC. The IJ began on [DATE] and ended [DATE]. The facility had corrected the noncompliance before the survey began. This failure could place residents at risk for injury and death.

Inspectors wroteBased on interview and record review the facility failed to ensure that all alleged violations involving abuse, are reported to Texas Health and Human Services Commision immediately, but not later than 2 hours after forming the suspicion, if the events that cause the suspicion result in serious bodily injury, or not later than 24 hours if the events that cause the suspicion do not result in serious bodily injury for 2 of 8 (Resident #32, Resident #246) residents reviewed for abuse and neglect. The facility did not report an allegation of abuse that occurred when Resident #247 touched Resident #32 on the breast on 10/12/2023. The facility did not report a significant medication error for Resident #246 that resulted in Resident #246 requiring hospitalization on 12/13/2023. This failure could place residents at risk of injuries, abuse, and/or neglect.

Inspectors wroteBased on observation, interview, and record review, the facility failed to store, prepare, distribute, and serve food under sanitary conditions in the facility's only kitchen. The facility failed to discard a boiled egg that was in a plastic bag in the refrigerator dated 2/8/2024. The facility failed to ensure the DM wore a hairnet effectively to cover all of her hair. These failures could place residents at risk for food-borne illnesses.

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 8 residents (Resident #39 and Resident #30) and 2 of 6 staff (Wound care nurse and CNA B) reviewed for infection control. The Wound care nurse failed to perform proper hand hygiene while providing wound care to Resident #39 on 02/13/2024. CNA B failed to perform hand hygiene while performing incontinent care to Resident #30 on 2/13/2024. These failures could place residents at risk of exposure to communicable diseases and infections.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure each resident was treated with respect, dignity, and care for 1 of 4 residents (Resident #26) observed for care in that: The ADON failed to sit while feeding Resident #26 in the dining room. This failure could affect residents in the facility who received care and could result in residents not being treated with dignity and respect.

Inspectors wroteBased on interview and record review the facility failed to ensure residents were free from abuse for 1 of 4 residents (Resident #32) reviewed for resident abuse. The facility did not ensure Resident #32 was free from abuse when Resident #247 touched Resident #32 on his right breast. This failure could place residents at risk of physical harm, mental anguish, or emotional distress.

Inspectors wroteBased on interview and record review, the facility failed to have evidence that allegations of sexual abuse were thoroughly investigated for 1 of 1 allegation reviewed for resident abuse. (Resident #32) The facility failed to ensure an allegation of sexual abuse on 10/12/23 for Resident #32 was thoroughly investigated. This failure could place residents at risk of sexual abuse and mental anguish due to allegations not being investigated as required.

Inspectors wroteBased on observation, interviews, and record review, the facility failed to provide the resident who was unable to carry out ADLs the necessary services to maintain good nutrition, grooming, and personal and oral hygiene for 2 of 4 residents (Resident #26 and Resident #35) observed for activities of daily living. The facility failed to ensure that Resident #26 and Resident #35's nails were kept clean and trimmed. This failure could place residents at risk of not receiving care and services to meet their needs which could result in poor care, risk for skin breakdown, feelings of poor self-esteem, lack of dignity and health. Findings Include: 1. [...]

Inspectors wroteBased on observation, interview, and record review, the facility failed to ensure the residents' environment remains as free of accident hazards as possible for 1 of 1 facility reviewed for accident hazards, in that: The facility failed to develop and implement a policy and procedure to properly handle care of Hoyer lift slings including laundry service which resulted in damaged slings, interventions to inspect the Hoyer sling for signs of damage before each use and not removing damaged slings from service. This deficient practice could result in a loss of quality of life due to injuries if the damaged lift sling broke during transfer for residents that use a Hoyer lift for transfers.

Inspectors wroteBased on observation, interview, and record review the facility failed to ensure the posted daily staffing information was posted in a prominent and high visible area for residents and visitors. The facility did not post the actual hours worked by licensed and unlicensed nursing staff directly responsible for care in the facility in a prominent place visible to the public.